Preferred
Drug List (PDL)
Ohio
Effective Date: 10/1/16
© 2016 United Healthcare Services, Inc. All rights reserved.
Preferred Drug List
INTRODUCTION
such information nor is it intended to be comprehensive in
nature.
This PDL is not intended to be a substitute for the
knowledge, expertise, skill and judgment of the medical
provider in their choice of prescription drugs.
UnitedHealthcare Community Plan is pleased to provide
this Preferred Drug List (PDL) to be used when prescribing
for patients covered by the pharmacy benefit plan offered
by UnitedHealthcare Community Plan. The drugs listed in
this PDL are intended to provide sufficient options to treat
patients who require treatment with a drug from that
pharmacologic or therapeutic class. The drugs listed in the
UnitedHealthcare Community Plan PDL have been
reviewed and approved by the UnitedHealthcare
Community Plan Pharmacy and Therapeutics Committee.
The drugs have been selected to provide the most clinically
appropriate and cost-effective medications for patients who
have their drug benefit administered through
UnitedHealthcare Community Plan. It is also recognized
there may be occasions where an unlisted drug is desired
for proper medical management of a specific patient. In
those infrequent instances, the unlisted medication may be
requested through the Medical prior authorization process.
This may also occur in cases where the medication is not
preferred on UnitedHealthcare Community Plan’s PDL, but
it is covered under the Ohio Medicaid Drug List. In these
cases, the medication may be requested through the
Medical prior authorization process.
UnitedHealthcare Community Plan 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.
National guidelines can be found on the Web sites listed in
the Web site section or go to the National Guideline
Clearinghouse site at http://www.guideline.gov.
The PDL and quarterly updates are also available on our
web site at www.uhccommunityplan.com.
PREFACE
The UnitedHealthcare Community Plan PDL is organized
by sections. Each section includes therapeutic groups
identified by either a drug class or disease state.
The drugs represented have been reviewed by the
UnitedHealthcare Community Plan Pharmacy and
Therapeutics (P&T) Committee and are approved for
inclusion. The PDL is reflective of current medical practice
as of the date of review.
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 included in
the PDL. Generics should be considered the first line of
prescribing.
This edition incorporates drugs added to the PDL since the
last edition as well as numerous revisions to the prescribing
information based on changes in pharmacotherapy.
Comments and suggestions from practicing physicians have
also been incorporated to ensure that the UnitedHealthcare
Community Plan PDL is reflective of current medical
practice.
The UnitedHealthcare Community Plan PDL covers
selected over-the-counter (OTC) products. Many are noted
in the drug lists; a complete list is included on page 44.
You are encouraged to prescribe OTC medications when
clinically appropriate.
NOTICE
The information contained in this PDL and its appendices is
provided by UnitedHealthcare Community Plan, solely for
the convenience of medical providers. UnitedHealthcare
Community Plan does not warrant or assure accuracy of
UHC1004a {Released 2/25/11}
i
drug list. There may also be a statement associated with a
drug list that gives additional information about which
specific products or dosage forms are covered.
PHARMACY AND THERAPEUTICS (P&T)
COMMITTEE
The UnitedHealthcare Community Plan P&T Committee
includes physicians and pharmacists who are not employees
or agents of UnitedHealthcare Community Plan or its
affiliates. They must adhere to the Ethics Policy standards
of the P&T Committee. UnitedHealthcare Community Plan
medical directors and pharmacists also participate in the
P&T Committee. UnitedHealthcare Community Plan’s
P&T Committee meets quarterly to discuss a variety of
issues. Those issues pertaining to pharmaceutical selection
and pharmacy program management are communicated
quarterly. This newsletter is distributed to all participating
physicians who have received UnitedHealthcare
Community Plan’s PDL. PDL decisions are also
communicated quarterly on the UnitedHealthcare
Community Plan internet site.
Products covered include all strengths associated
with the dosage form of the cited brand name
product.
carvedilol
All strengths of Coreg would be covered by this listing.
Extended-release and delayed-release products
require their own entry.
diltiazem sustained release CARDIZEM SR
Dosage forms covered will be consistent with the
category and use where listed.
OUTPATIENT PRESCRIPTION DRUG
BENEFIT-COVERED MEDICATIONS
Neomycin/polymixin B/ Cortisporin
Hydrocortisone
Medically necessary outpatient prescription drugs are
covered when prescribed by a provider licensed to
prescribe federal legend drugs or medicines. Some items
are covered only with prior authorization.
As listed in the OTIC section, this is limited to the otic
solution and suspension. From this entry the ophthalmic
solution and ointment, and the topical cream cannot be
assumed to be on the list unless there are entries for these
products in the OPHTHALMIC and DERMATOLOGY
sections of the PDL.
PRODUCT SELECTION CRITERIA
The UnitedHealthcare Community Plan P&T Committee
considers clinical information on new-to-market drugs that
are typically included in an outpatient pharmacy benefit.
The evaluation includes all or part of the following:
• 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 PDL inclusion, it will
be reviewed relative to similar drugs currently included in
the UnitedHealthcare Community Plan PDL. This review
process may result in deletion of drug(s) in a particular
therapeutic class in an effort to continually promote the
most clinically useful and cost-effective agents.
When a strength or dosage form is specified, only the
specified strength and dosage form is on the PDL.
Other strengths/dosage forms of the reference product
are not
citalopram 40 mg tabs
Celexa tabs
GENERIC SUBSTITUTION
The UnitedHealthcare Community Plan PDL requires
generic substitution on the majority of products when a
generic equivalent is available.
Generic substitution is a pharmacy action whereby a
generic equivalent is dispensed rather than the brand name
product. The PDL indicates generic availability in the
“Covered Drug” column.
If a brand name drug is medically necessary, please submit
a prior authorization request.
All the information in the PDL is provided as a reference
for drug therapy selection. Specific drug selection for an
individual patient rests solely with the prescriber.
The UnitedHealthcare Community Plan MAC list sets a
ceiling price for the reimbursement of certain multisource
prescription drugs. This price will typically cover the
acquisition of most generics but not branded versions of the
same drug. The products selected for inclusion on the
MAC list are commonly prescribed and dispensed and have
usually gone through the FDA’s review and approval
process. An important consideration for generic
substitution is the knowledge that all approvals of generic
PDL PRODUCT DESCRIPTIONS
To assist in understanding which specific strengths and
dosage forms are covered on the
PDL, examples are noted below. The general principles
shown in the examples can then usually be extended to
other entries in the book. Any exceptions are noted in the
UHC1004a
Coreg
ii
drugs by the FDA since 1984, and many generic approvals
prior to 1984, have a showing of bioequivalence between
the generic versions and the reference brand product. To
gain FDA approval:
PLAN EXCLUSIONS
The following drug categories are excluded from coverage
under the outpatient pharmacy benefit and are not part of
the UnitedHealthcare Community Plan PDL.
• DESI drugs
• Antiobesity agents
• Experimental / research drugs
• Cosmetic drugs
• Immunization agents*
• Nutritional / diet supplements*
• Blood and blood plasma products
• Agents used to promote fertility
• Agents used for erectile dysfunction
• Agents used for cosmetic hair growth
• Drugs from manufacturers that do not participate
in the FFS Medicaid Drug Rebate Program
• Diagnostic products
• Medical supplies and DME except as listed:
syringes, needles, lancets, alcohol swabs, spacers,
preferred diabetes test strips, peak flow meters
(Astech, Assess, Peak Air brands, max two per
year), vaporizer (limit of 1 per 3 years), humidifier
(limit of 1 per 3 years)
• Mirena*
1. The generic drug must contain the same active
ingredient(s), be the same strength and the same dosage
form as the brand name product.
2. 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 brand name product.
*Coverage provided as part of the Medical benefit
DAYS SUPPLY DISPENSING LIMITATIONS
UnitedHealthcare Community Plan members may receive
up to a one month supply of a specific medication per
prescription order or prescription refill. A medication may
be reordered or refilled when eighty-five percent (85%) of
the medication has been utilized. If a claim is submitted
before 85% of the medication has been used, based on the
original day supply submitted on the claim, the claim will
reject with a "refill too soon" message. Please call the
UnitedHealthcare Community Plan Pharmacy Department
at 800-310-6826 with questions or for help with dosage
change authorization.
There are now many brand name products that are
repackaged or distributed under a generic label. The generic
label version should always be considered therapeutically
equivalent and substitutable for the source branded product.
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 by the FDA to review the
effectiveness of these pre-1962 drugs for their labeled
indications, 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. UnitedHealthcare Community
Plan’s PDL does not cover DESI “less than fully effective”
drug products.
UHC1004a
MANDATORY GENERIC SUBSTITUTION
The UnitedHealthcare Community Plan PDL requires
mandatory generic substitution on the vast majority of
products when a generic equivalent is available; however,
brand name drugs may be covered in certain situations by
requesting a prior authorization. The UnitedHealthcare
Community Plan PDL prior authorization (PA) list does not
include branded items where a generic equivalent is
covered.
PRIOR AUTHORIZATION OF NON-PDL
MEDICATIONS
The drugs in the UnitedHealthcare Community Plan PDL
have been selected to provide the most clinically
appropriate and cost-effective medications for patients who
have their drug benefit administered through
UnitedHealthcare Community Plan. It is also recognized
iii
medication. The pharmacist must contact the plan to
obtain a manual 15-day override. Before the next
dispensing, the pharmacy must contact the physician to
discuss a PDL drug or if a prior authorization request is
warranted. If the prescribing physician feels a drug is
medically necessary, the physician may fax a request for
prior authorization to UnitedHealthcare Community Plan at
866-940-7328, Attn: Pharmacy Department.
that there may be occasions where an unlisted drug is
desired for the proper medical management of a specific
patient. In those infrequent instances, the prior
authorization process reviews requests for unlisted
medications the physician may consider medically
necessary for patient management. This may also occur in
cases where the medication is not preferred on
UnitedHealthcare Community Plan’s PDL, but it is covered
under the Ohio Medicaid Drug List. In these cases, the
medication may be requested through the Medical prior
authorization process.
QUANTITY LIMITATIONS (QL)
Prescriptions for monthly quantities greater than the
indicated limit require a prior authorization request.
Requests for these exceptions should be made in writing by
the physician and faxed or mailed to:
Quantity limits based on Efficient Medication Dosing
The Efficient Medication Dosing Program is designed to
consolidate medication dosage to the most efficient daily
quantity to increase adherence to therapy and also promote
the efficient use of health care dollars.
The limits for the program are established based on FDA
approval for dosing and the availability of the total daily
dose in the least amount of tablets or capsules daily.
Quantity Limits in the prescription claims processing
system will limit the dispensing to consolidate dosing. The
pharmacy claims processing system will prompt the
pharmacist to request a new prescription order from the
physician.
UnitedHealthcare Community Plan
Pharmacy Services Department
1001 Brinton Road
Pittsburgh, PA 15221
Fax 866-940-7328
Phone 800-310-6826
A prior authorization request form is available in the
UnitedHealthcare Community Plan provider manual and
should be used for all prior authorization requests if
possible. Appropriate documentation must be provided to
support the medical necessity of the non-PDL request. The
UnitedHealthcare Community Plan Pharmacy Department
will respond to all requests in accordance with state
requirements.
Controlled Substances
You may fill any FOUR medications from the following
classes in a 30-day period:
• opiate analgesics
• benzodiazepines
• sedative hypnotic agents
• barbiturates
• select muscle relaxants
Physicians are requested to adhere to this PDL when
prescribing for patients covered by their pharmacy benefit
plan offered by UnitedHealthcare Community Plan. If a
pharmacist receives a prescription for a non-PDL drug, the
pharmacist should contact the prescribing physician and
request that the prescription be changed to a medication
included in this PDL. If a PDL alternative is not
appropriate the physician should then be instructed to
contact the Plan for a prior authorization.
Please contact the UnitedHealthcare Community Plan
Pharmacy Department at 800-310-6826 with questions
concerning the prior authorization process.
Additional fills will require prior authorization.
Medications in these classes may also be subject to
individual quantity limits.
Additions to the QL program drug list will be made from
time to time and providers notified accordingly. As always,
we recognize that a number of patient-specific variables
must be taken into consideration when drug therapy is
prescribed and therefore overrides will be available through
the medical exception (prior authorization) process. Please
contact the UnitedHealthcare Community Plan Pharmacy
Department at 800-310-6826 with questions.
NON-PDL DRUGS 5-DAY AND 15-DAY OVERRIDES
To ensure the use of PDL drugs, all non- PDL drugs should
be discussed with the prescribing physician. If you cannot
speak to the physician immediately, and there is an
immediate need for the medication, the claim processing
system will accept an override to permit a one-time
dispensing of a 5-day supply of the newly prescribed
non-PDL drug. The pharmacy should submit a claim for a
5 day supply, with a PA Type of 8 and Prior Authorization
number of “00000000120”. Please note that non-preferred
drugs are available for a 5-day supply. For assistance,
pharmacies may call 800-310-6826.
Pharmacies may dispense a one-time, 15-day supply to
members requiring an immediate supply of an ongoing
UHC1004a
Specialty Pharmaceutical Management Program
UnitedHealthcare Community Plan is continuously looking
for ways to provide high quality cost effective care for Plan
members. The Specialty Pharmaceutical Management
Program helps UnitedHealthcare Community Plan to
achieve these goals.
Injectable medications that are part of this program require
plan authorization and are not available through the retail
pharmacy network.
iv
calcitriol
3mcg/gm
To obtain authorization, the provider must submit the
appropriate Prior Authorization form to the
UnitedHealthcare Community Plan Pharmacy Department
via fax at 866-940-7328.
The UnitedHealthcare Community Plan Pharmacy
Department will review and respond to all requests in
accordance with state requirements, and if authorized for
payment, UnitedHealthcare Community Plan will
coordinate the delivery of the product to the member or
provider.
Drugs that are part of this program and are on the PDL are
identified in this booklet by the designation "SP".
Prior Authorization request forms can be requested by
calling the UnitedHealthcare Community Plan Pharmacy
Department 800-310-6826.
DPP4 Inhibitors At least a 90 day trial of 1500mg/day of
(Tradjenta,
metformin.
Jentadueto,
Onglyza, Kombiglyze)
MEDICATIONS REQUIRING DIAGNOSIS
UnitedHealthcare Community Plan requires that the
diagnosis for prescriptions for HIV medications for
UnitedHealthcare Community Plan Community Plan
members match the FDA-approved use or a use supported
by current published evidence.
The diagnosis will be verified at the point-of-sale by the
pharmacy claims processing system. If a matching
diagnosis is not found in the medical claim file or on the
pharmacy drug claim, the prescription will be rejected at
the pharmacy. The pharmacist may then contact the
prescriber to verify the diagnosis and submit it on the
claim.
Aricept 23mg
90 day trial of Aricept 10mg daily
Breo Ellipta
1) 30 day trial of one inhaled
corticosteroid (e.g. Arnuity Ellipta,
Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Arcapta,
Striverdi) OR 60 day trial of an orally
inhaled anticholinergic agent (e.g. Incruse
Ellipta, Atrovent, Combivent, Anoro
Ellipta).
UHC1004a
Elidel
Trial of two different topical
corticosteroids. Step therapy only applies
to members 12 years of age and older.
fenofibrate
Fill of a statin or 90 days of gemfibrozil
within the previous 180 days.
Lantus vials
trial of Toujeo Solostar
Optivar
14 day trial of ketotifen within previous
90 days required first.
Ranexa
Trial of one drug from the following
classes: beta blockers, calcium channel
blockers, long acting nitrates
Renvela
8 week trial of calcium acetate.
SGLT-2
At least a 90 day trial of 1500mg/day of
Inhibitors
metformin
(Jardiance,
Invokana,
Invokamet, Synjardy)
First-Line Agent(s)
Trial at a minimum dose of 50mg of
sumatriptan tablets.
1) 30 day trial of one inhaled
corticosteroid (e.g. Arnuity Ellipta,
Asmanex) OR 2) 60 day trial of a longacting beta2- agonist (e.g. Arcapta,
Striverdi) OR 60 day trial of an orally
inhaled anticholinergic agent (e.g. Incruse
Ellipta, Atrovent, Combivent, Anoro
Ellipta).
oxymorphone ER 30-day trial of both Fentanyl patch and
(non-crush
morphine sulfate ER at least 200mg per
resistant)
day
STEP THERAPY (ST)
The following PDL drugs are routinely covered only after a
sufficient trial of an indicated first-line agent has been
adequately tried and failed. These medications may also be
requested through the Prior authorization process.
While lower cost PDL alternatives may be appropriate in
many instances, other non- PDL alternatives are available
with prior authorization (PA).
Amerge
Dulera
GLP-1 Agonists At least a 90 day trial of 1500mg/day of
(Tanzeum,
metformin
Victoza)
If the diagnosis provided still does not match the approved
use, prior authorization may be requested through the
standard process by faxing a request to 866-940-7328.
STEP Drug
Trial of two topical corticosteroids
tacrolimus 0.03%Trial of two different topical
corticosteroids. Step therapy only applies
to members 12 years of age and older.
tacrolimus 0.1% Minimum age of 16. Trial of two
different topical corticosteroids
v
tolterodine
30 day trial of oxybutynin immediate
release. Step Therapy only applies to
members less than 65 years of age.
trospium
30 day trial of oxybutynin immediate
release. Step Therapy only applies to
members less than 65 years of age.
EDITOR
Your comments and suggestions regarding the
UnitedHealthcare Community Plan PDL are encouraged.
Your input is vital to this PDL’s continued success. All
responses will be reviewed and considered. Please send
your comments to:
UnitedHealthcare Community Plan
Director of Pharmacy Services
1001 Brinton Road
Pittsburgh, PA 15221
Phone: 800-310-6826
Email: pdl_management@uhc.com
Internet: http://www.uhccommunityplan.com
TZD’s
At least a 90 day trial of 1500mg/day of
(ActosPlusMet, metformin
ActoPlusMet XR,
Duetact)
Uloric
8 week trial of up to 600mg of
allopurinol required first.
Vancocin
One fill of metronidazole tabs or cap
Xopenex
Respules
30 day trial of Albuterol .083% or .5%
respules.
Zohydro ER
30-day trial of both Fentanyl patch and
morphine sulfate ER at least 200mg per
day
LEGEND
#
Only the dosage forms/strengths of the brand
name products noted are on the PDL
OTC
over-the-counter
delayed-rel delayed-release (also known as enteric coated)
EC
enteric-coated
ext-rel
extended-release (also known as sustainedrelease)
PA
Prior Authorization required
QL
Quantity Limits apply
ST
Step Therapy, see pages V-VI for details
SP
Specialty Pharmaceuticals, see page V for
details
PDL SUGGESTIONS
Providers who wish to propose PDL suggestions should
forward the information to the UnitedHealthcare
Community Plan Director of Pharmacy Services by either
mail or fax.
NOTICE
The information contained in this document is proprietary
information. The information may not be copied in whole
or in part without the written permission of
UnitedHealthcare Community Plan. All rights reserved.
Attn: Director of Pharmacy Services
UnitedHealthcare Community Plan
1001 Brinton Road
Pittsburgh, PA 15221
Fax: 866-940-7328
Email: pdl_management@uhc.com
The drug names listed here are the registered and/or
unregistered trademarks of third-party pharmaceutical
companies unrelated to and unaffiliated with
UnitedHealthcare Community Plan. These trademarked
brand names are included here for informational purposes
only and are not intended to imply or suggest any
affiliation between UnitedHealthcare Community Plan and
such third-party pharmaceutical companies.
If viewing this PDL via the Internet, please be advised that
the PDL is updated periodically and changes may appear
prior to their effective date to allow for notification.
Providers should furnish adequate documentation, such as
clinical studies from the medical literature, in order for the
request to be considered for PDL addition. This literature
should include information documenting clinical necessity
as well as therapeutic advantages over current PDL
products. Suggestions received by UnitedHealthcare
Community Plan will be reviewed by the Pharmacy and
Therapeutics Committee at the subsequent P&T Committee
meeting.
UHC1004a
vi
Table of Contents
Antineoplastics & Immunosuppressants . . . 4
Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . 4
Hormonal Antineoplastic Agents . . . . . . . . . . . . . 5
Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . 5
Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . 6
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . 15
Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 16
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 17
Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Scabies and Pediculosis . . . . . . . . . . . . . . . . . . 18
Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Blood Modifiers - Anticoagulants . . . . . . . . . 6
Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Blood Cell Formation . . . . . . . . . . . . . . . . . . . . . . . 7
Platelet Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . . 19
Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 21
Cardiovascular Agents . . . . . . . . . . . . . . . . . 7
Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Ace Inhibitor/Diuretic Combinations . . . . . . . . . . 8
Adrenolytics, Central . . . . . . . . . . . . . . . . . . . . . . . 8
Alpha Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Angiotensin II Receptor Blockers (Antagonists) . 8
Angiotensin II Receptor Blocker Combinations . 8
Antiarrhythmics and Cardiac Glycosides . . . . . . 8
Beta Blockers and Beta Blocker/Diuretic
Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Calcium Channel Blockers . . . . . . . . . . . . . . . . . . 9
Calcium Channel Blockers/ACE Inhibitor
Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Lipid Lowering Agents . . . . . . . . . . . . . . . . . . . . 10
Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Potassium-Removing Agents . . . . . . . . . . . . . . 11
Pulmonary Arterial Hypertension . . . . . . . . . . . 11
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Endocrinology . . . . . . . . . . . . . . . . . . . . . . . 21
Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 21
Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 21
Growth Stimulating Agents . . . . . . . . . . . . . . . . 23
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . 23
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . 23
Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Emesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Gastroesophageal Reflux Disease (Gerd)/
Peptic Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . 25
Inflammatory Bowel Disease . . . . . . . . . . . . . . . 25
Laxatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 26
Probiotic Supplementation . . . . . . . . . . . . . . . . 26
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Central Nervous System . . . . . . . . . . . . . . . 11
Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 11
Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 13
Migraine Prophylactic Therapy . . . . . . . . . . . . . 14
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . 14
Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . 14
Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 14
Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Infectious Diseases . . . . . . . . . . . . . . . . . . . 26
Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2
Musculoskeletal . . . . . . . . . . . . . . . . . . . . . . 31
Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 32
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 52
Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 53
Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 53
Idiopathic Pulmonary Fibrosis (IPF) . . . . . . . . . 53
Immune Thrombocytopenic Purpura . . . . . . . . 53
Medical Devices . . . . . . . . . . . . . . . . . . . . . . . . . 53
Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . 53
Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Hormone Therapy/Menopause . . . . . . . . . . . . 33
Vaginal Infections . . . . . . . . . . . . . . . . . . . . . . . . 34
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 35
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
OTC MEDICATIONS . . . . . . . . . . . . . . . . . . . 55
Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 55
Cough/Cold Allergy . . . . . . . . . . . . . . . . . . . . . . 55
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Earwax Removal Products . . . . . . . . . . . . . . . . 56
Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 56
First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Motion Sickness . . . . . . . . . . . . . . . . . . . . . . . . . 57
Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Smoking Cessation Products . . . . . . . . . . . . . . 58
Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . 58
Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Psychiatric . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Alcohol Deterrents . . . . . . . . . . . . . . . . . . . . . . . 37
Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Attention Deficit Hyperactivity Disorder (ADHD) .
37
Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . 38
Depression* . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Medications Coverable for Participating
Behavioral Health Prescribers± . . . . . . . . . . . . 39
Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . 41
Psychoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . 41
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Index of Covered Drugs . . . . . . . . . . . . . . . . 59
Respiratory Drugs . . . . . . . . . . . . . . . . . . . . 42
Antitussives, Decongestants, Expectorants And
Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Symptomatic Benign Prostatic Hypertrophy . . 48
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Vitamins and Minerals . . . . . . . . . . . . . . . . . 48
Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Antineoplastics & Immunosuppressants
Antineoplastic Agents
Alkylating Agents
altretamine
busulfan
chlorambucil
cyclophosphamide
cyclophosphamide
estramustine
phosphate sodium
lomustine
melphalan
temozolomide
HEXALEN
MYLERAN
LEUKERAN
CYCLOPHOSPH
CYTOXAN
GLEOSTINE
ALKERAN
TEMODAR
brand
brand
generic
capecitabine
mercaptopurine
thioguanine
trifluridine/tipiracil
XELODA
PURINETHOL
TABLOID
LONSURF
generic
generic
brand
brand
QL
PA, SP
panobinostat
vorinostat
FARYDAK
ZOLINZA
brand
brand
PA, SP
PA, SP
afatinib
alectinib
axitinib
bosutinib
cabozantinib
ceritinib
cobimetinib
crizotinib
dabrafenib
dasatinib
erlotinib
GILOTRIF
ALECENSA
INLYTA
BOSULIF
COMETRIQ
ZYKADIA
COTELLIC
XALKORI
TAFINLAR
SPRYCEL
TARCEVA
AFINITOR
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
brand
PA, SP
brand
brand
brand
generic
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, QL, SP
PA, SP
PA, SP
PA, SP
Antimetabolites
brand
brand
brand
generic
generic
EMCYT
brand
Histone Deacetylase Inhibitors
Kinase Inhibitor
everolimus
gefitinib
ibrutinib
idelalisib
imatinib mesylate
lapatinib ditosylate
lenvatinib
nilotinib
AFINITOR DISPERZ
IRESSA
IMBRUVICA
ZYDELIG
GLEEVEC
TYKERB
LENVIMA
TASIGNA
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
inj 500 mg, PA
ST = Step Therapy
SP = Specialty Pharmacy
4
PA, SP
SP
*Available without PA for
participating Behavioral Health
Prescribers
Covered
Drug
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
Generic Drug Name
Brand Drug Name
palbociclib
pazopanib
ponatinib
regorafenib
ruxolitinib
sorafenib
sunitinib
trametinib
vandetanib
vemurafenib
IBRANCE
VOTRIENT
ICLUSIG
STIVARGA
JAKAFI
NEXAVAR
SUTENT
MEKINIST
CAPRELSA
ZELBORAF
ixazomib
NINLARO
brand
PA, SP
abiraterone
ZYTIGA
brand
PA, SP
bicalutamide
flutamide
CASODEX
EULEXIN
generic
generic
tamoxifen
toremifene
NOLVADEX
FARESTON
generic
brand
anastrozole
exemestane
letrozole
ARIMIDEX
AROMASIN
FEMARA
generic
generic
generic
leuprolide
LUPRON
LUPRON DEPOT
generic
PA, SP
leuprolide
LUPRON DEPOT 6-MONTH
brand
PA, SP
Proteasome Inhibitors
Hormonal Antineoplastic Agents
Androgen Biosynthesis Inhibitors
Antiandrogens
Antiestrogens
Aromatase Inhibitors
Gonadotropin Releasing Hormone Analog
Progestin
Requirements & Limits
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
LUPRON DEPOT-PED
megestrol acetate
MEGACE
generic
interferon alfa-2b
INTRON A
brand
peginterferon alfa-2b
SYLATRON
brand
3,000,000 unit/0.2 ML only,
PA, SP
PA, SP
lenalidomide
pomalidomide
REVLIMID
POMALYST
brand
brand
PA, SP
PA, SP
Immunomodulators
Interferons
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
5
*Available without PA for
participating Behavioral Health
Prescribers
Brand Drug Name
Covered
Drug
azathioprine
mycophenolate mofetil
mycophenolate sodium
IMURAN
CELLCEPT
MYFORTIC
generic
generic
generic
cyclosporine
SANDIMMUNE
GENGRAF
generic
Generic Drug Name
Immunosuppressants
Antimetabolites
Calcineurin Inhibitors
cyclosporine, modified
tacrolimus
Other
generic
NEORAL
HECORIA
Requirements & Limits
caps, QL
generic
PROGRAF
everolimus
ZORTRESS
brand
sirolimus
sirolimus
RAPAMUNE
RAPAMUNE
generic
brand
tabs
soln
alitretinoin 1% gel
bexarotene caps and
topical gel
cysteamine bitartrate
etoposide
hydroxyurea
hydroxyurea
leucovorin calcium
mesna tab
mitotane
octreotide
olaparib
pasireotide
procarbazine
sonidegib
thalidomide
topotecan
tretinoin
vismodegib
PANRETIN
brand
PA
TARGRETIN
brand
PA
brand
generic
brand
generic
generic
brand
brand
generic
brand
brand
brand
brand
brand
brand
generic
brand
PA
PA
PA, SP
PA, SP
Rapamycin Derivative
Miscellaneous
CYSTAGON
VEPESID
DROXIA
HYDREA
WELLCOVORIN
MESNEX
LYSODREN
SANDOSTATIN
LYNPARZA
SIGNIFOR
MATULANE
ODOMZO
THALOMID
HYCAMTIN
VESANOID
ERIVEDGE
PA, SP
PA, SP
PA, SP
caps
PA, SP
Blood Modifiers - Anticoagulants
Anticoagulants
apixaban
edoxaban
ELIQUIS
SAVAYSA
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
brand
ST = Step Therapy
SP = Specialty Pharmacy
6
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
PA, QL, SP,
SP and PA only applies for
quantities greater than
14 days
enoxaparin
LOVENOX
generic
heparin
rivaroxaban
warfarin
HEPARIN
XARELTO
generic
brand
generic
darbepoetin alfa
ARANESP
EPOGEN
brand
PA, SP
brand
PA, SP
brand
brand
brand
brand
brand
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
Blood Cell Formation
epoetin alfa
filgrastim
oprelvekin
pegfilgrastim
plerixafor
sargramostim
Platelet Inhibitors
anagrelide
aspirin
PROCRIT
ZARXIO
NEUMEGA
NEULASTA
MOZOBIL
LEUKINE
AGRYLIN
BAYER
cilostazol
clopidogrel
dipyridamole
ECOTRIN
PLETAL
PLAVIX
PERSANTINE
aminocaproic acid
AMICAR
Miscellaneous
deferasirox
pentoxifylline
extended-release
generic
generic
OTC
generic
generic
generic
QL
brand
EXJADE
brand
JADENU
TRENTAL
generic
benazepril
captopril
enalapril
LOTENSIN
CAPOTEN
VASOTEC
generic
generic
generic
enalapril oral soln
EPANED
fosinopril
lisinopril
moexipril hcl
perindopril erbumine
MONOPRIL
ZESTRIL
UNIVASC
ACEON
500 mg tabs & syrup only
PA, SP
Cardiovascular Agents
Ace Inhibitors
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
generic
generic
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
7
Members ≥ 8 years of age will
require prior authorization.
QL
QL
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
quinapril
trandolapril
ACCUPRIL
MAVIK
Covered
Drug
generic
generic
LOTENSIN HCT
generic
CAPOZIDE
generic
VASERETIC
generic
MONOPRIL-HCT
generic
QL
ZESTORETIC
generic
QL
UNIRETIC
generic
ACCURETIC
generic
clonidine
clonidine transdermal
guanfacine
CATAPRES
CATAPRES- TTS
TENEX
generic
generic
generic
doxazosin
prazosin
terazosin
CARDURA
MINIPRESS
HYTRIN
generic
generic
generic
losartan
COZAAR
generic
QL
losartan/HCTZ
HYZAAR
generic
QL
amiodarone tabs
digoxin
disopyramide
disopyramide
extended-release
dofetilide
flecainide
mexiletine
propafenone
quinidine gluconate extended-release
quinidine sulfate
CORDARONE
LANOXIN
NORPACE
generic
generic
generic
200 mg and 400 mg
NORPACE CR
brand
Ace Inhibitor/Diuretic Combinations
benazepril/
hydrochlorothiazide
captopril/
hydrochlorothiazide
enalapril/
hydrochlorothiazide
fosinopril/
hydrochlorothiazide
lisinopril/
hydrochlorothiazide
moexiprilhydrochlorothiazide
quinapril/
hydrochlorothiazide
Adrenolytics, Central
Alpha Blockers
Angiotensin II Receptor Blockers (Antagonists)
Angiotensin II Receptor Blocker Combinations
Antiarrhythmics and Cardiac Glycosides
TIKOSYN
TAMBOCOR
MEXITIL
RYTHMOL
QUINIDINE GLUCONATE
EXT-REL
QUINIDINE SULFATE
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
generic
generic
generic
QL
QL
IR only
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
8
Requirements & Limits
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
Covered
Drug
quinidine sulfate
extended-release
QUINIDINE SULFATE
EXT-REL
generic
acebutalol
atenolol
atenolol/chlorthalidone
bisoprolol
bisoprolol/
hydrochlorothiazide
carvedilol
labetalol
metoprolol
metoprolol succinate
nadolol
pindolol
propranolol
propranolol HCL
propranolol/HCTZ
sotalol
timolol maleate
SECTRAL
TENORMIN
TENORETIC
ZEBETA
generic
generic
generic
generic
ZIAC
generic
COREG
TRANDATE
LOPRESSOR
TOPROL XL
CORGARD
PINDOLOL
INDERAL
INDERAL LA
INDERIDE
BETAPACE
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
amlodipine
felodipine
extended-release
nicardipine
nifedipine
nifedipine
extended-release
nimodipine
nimodipine oral soln
NORVASC
generic
QL
PLENDIL
generic
QL
CARDENE
PROCARDIA
ADALAT CC
generic
generic
diltiazem
diltiazem
extended-release
diltiazem
extended-release
diltiazem
sustained-release
verapamil
verapamil
extended-release
CARDIZEM
generic
CARDIZEM CD
generic
QL
generic
QL
CARDIZEM SR
generic
QL
CALAN
generic
CALAN SR
generic
Requirements & Limits
Beta Blockers and Beta Blocker/Diuretic Combinations
Calcium Channel Blockers
Dihydropyridines
Nondihydropyridines
PROCARDIA XL
NIMOTOP
NYMALIZE
DILACOR XR
TIAZAC
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
50 mg and 100 mg only
tablets
generic
QL
generic
brand
QL
ST = Step Therapy
SP = Specialty Pharmacy
9
QL
QL
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Calcium Channel Blockers/ACE Inhibitor Combination
amlodipine-benazepril
LOTREL
generic
amiloride
amiloride/
hydrochlorothiazide
bumetanide
chlorothiazide
MIDAMOR
generic
MODURETIC
generic
BUMEX
DIURIL
DIURIL ORAL
SUSPENSION
CHLORTHALIDONE
LASIX
HYDROCHLOROTHIAZIDE
MICROZIDE
LOZOL
ZAROXOLYN
ALDACTONE
generic
generic
ALDACTAZIDE
generic
DEMADEX
DYAZIDE
generic
Diuretics
chlorothiazide
chlorthalidone
furosemide
hydrochlorothiazide
hydrochlorothiazide
indapamide
metolazone
spironolactone
spironolactone/
hydrochlorothiazide
torsemide
triamterene/
hydrochlorothiazide
Lipid Lowering Agents
Bile Acid Resin
cholestyramine
Fibrates
brand
generic
generic
generic
generic
generic
generic
generic
QL
soln, tabs
12.5 mg caps
generic
MAXZIDE
QUESTRAN
generic
QUESTRAN-LIGHT
Only the bulk products are
covered (cans). Individual
packets are not covered.
fenofibrate
fenofibrate
gemfibrozil
LIPOFEN
LOFIBRA
LOPID
brand
generic
generic
atorvastatin
lovastatin
simvastatin
LIPITOR
MEVACOR
ZOCOR
generic
generic
generic
QL
QL
fish oil caps
inositol niacinate
FISH OIL
NIACINOL
generic
generic
OTC
500 mg caps only, OTC
niacin
niacin extended-release
NIACOR
NIASPAN
generic
generic
alirocumab
PRALUENT
HMG-CoA Reductase Inhibitors and Combinations
Others
Niacins
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
ST = Step Therapy
SP = Specialty Pharmacy
10
cap, PA
ST
PA, QL, SP
*Available without PA for
participating Behavioral Health
Prescribers
Covered
Drug
brand
Generic Drug Name
Brand Drug Name
ezetimibe
ZETIA
isosorbide dinitrate
isosorbide dinitrate
extended-release
isosorbide mononitrate
isosorbide mononitrate
extended-release
ISORDIL
ISOSORBIDE
DINITRATE ER
ISMO
generic
IMDUR
generic
isosorbide dinitrate
nitroglycerin
nitroglycerin
ISORDIL S.L.
NITROLINGUAL
NITROSTAT
generic
generic
brand
Nitrates
Oral
Sublingual
Transdermal
nitroglycerin
nitroglycerin
PA
generic
generic
NITREK
generic
transdermal, not 0.3 mg or
0.8 mg, QL
oint
KALEXATE
generic
powder
KAYEXALATE
generic
susp (susp only)
generic
NITRO-DUR
NITRO-BID
Potassium-Removing Agents
sodium polystyrene
sulfonate
sodium polysterene
sulfonate
Requirements & Limits
Pulmonary Arterial Hypertension
ambrisentan
bosentan
macitentan
riociguat
sildenafil
LETAIRIS
TRACLEER
OPSUMIT
ADEMPAS
REVATIO
brand
brand
brand
brand
generic
PA, SP
PA, SP
PA, SP
PA, SP
PA
guanabenz
hydralazine
methyldopa
methyldopa/HCTZ
midodrine
minoxidil
ranolazine
WYTENSIN
APRESOLINE
ALDOMET
ALDORIL
PROAMATINE
LONITEN
RANEXA
generic
generic
generic
generic
generic
generic
brand
ST
Miscellaneous
Central Nervous System
Alzheimer’s Disease
donepezil
ARICEPT
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
ST = Step Therapy
SP = Specialty Pharmacy
11
5 mg and 10 mg, QL,
Members <18 years of age
will require prior authorization.
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Covered
Drug
Brand Drug Name
donepezil
ARICEPT
generic
galantamine
RAZADYNE
generic
memantine
NAMENDA
generic
rivastigmine
EXELON
generic
Analgesics
Barbiturate Non-Narcotic Analgesics
butalbital/acetaminophen
PHRENILIN
SEDAPAP
butalbital/acetaminophen/
FIORICET
caffeine
butalbital/aspirin/caffeine FIORINAL
Non-Narcotic Analgesics
Requirements & Limits
23 mg, ST, Members <18
years of age will require prior
authorization.
QL, Members <18 years
of age will require prior
authorization.
QL, Members <18 years
of age will require prior
authorization.
PA req for soln, QL, Members
<18 years of age will require
prior authorization.
generic
QL
generic
QL
generic
QL
acetaminophen
aspirin/acetaminophen/
caffeine
tramadol
TYLENOL
generic
OTC
EXCEDRIN MIGRAINE
generic
250-250-65 mg, OTC
ULTRAM
generic
QL
etodolac
LODINE
generic
ibuprofen
ADVIL
generic
ibuprofen
MOTRIN
generic
NSAIDS
INDOCIN
ORUDIS
TORADOL
MOBIC
NAPROSYN
ENTERIC COATEDnaproxen delayed release
NAPROSYN
oxaprozin
DAYPRO
piroxicam
FELDENE
sulindac
CLINORIL
indomethacin
ketoprofen
ketorolac tromethamine
meloxicam
naproxen
generic
generic
generic
generic
generic
generic
generic
generic
FIORICET W/CODEINE
FIORINAL W/CODEINE
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
QL
QL
generic
Opioids — Narcotic Analgesics
butalbital/apap/caff/cod
butalbital/asa/caff/cod
tabs, chew tabs
and susp, OTC
tabs, chew tabs
and susp
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
12
QL, 50-325-40-30 mg
QL
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
butorphanol
codeine/acetaminophen
codeine sulfate
fentanyl transdermal
STADOL
TYLENOL W/CODEINE
DURAGESIC
LORCET
Covered
Drug
generic
generic
generic
generic
Requirements & Limits
nasal spray, QL
QL
QL
QL
LORTAB
hydrocodone/
acetaminophen
LORTAB ELIXIR
generic
QL
VICODIN ES
ZOHYDRO ER
DILAUDID
DEMEROL
DOLOPHINE
MSIR
RMS
brand
generic
generic
generic
generic
generic
ST
QL
QL
not 40 mg tabs, QL
QL
QL
MS CONTIN
generic
QL
OXYFAST
ROXICODONE
generic
generic
oxycodone/
acetaminophen
PERCOCET
generic
oxycodone/aspirin
oxymorphone ER
pentazocine/naloxone
PERCODAN
OXYMORPHONE ER
TALWIN NX
generic
generic
generic
soln, QL
QL
2.5/325, 5/325, 7.5/325,
10/325, 7.5/500 and
10/650, QL
QL
QL, ST, non-crush resistant
QL
dihydroergotamine
dihydroergotamine
ergotamine/caffeine
ergotamine tartrate/
caffeine
D.H.E. 45
MIGRANAL
CAFERGOT
MIGERGOT
SUPPOSITORIES
generic
generic
generic
inj, QL
brand
QL
naratriptan
rizatriptan
sumatriptan
AMERGE
MAXALT/MAXALT MLT
IMITREX
IMITREX
4 MG AND 6 MG INJ
TREXIMET
generic
generic
generic
ST
QL
QL
generic
4 mg and 6 mg inj
brand
PA
NORCO
VICODIN
hydrocodone ER
hydromorphone
meperidine
methadone
morphine
morphine
morphine
extended-release
oxycodone
oxycodone
Migraine Acute Therapy
Ergotamine Derivatives
Selective Serotonin Agonists
sumatriptan
sumatriptan-naproxen
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
13
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Covered
Drug
Brand Drug Name
Migraine Prophylactic Therapy
Requirements & Limits
amitriptyline
divalproex sodium
cap sprinkle
divalproex sodium
delayed-release
propranolol
verapamil
ELAVIL
generic
DEPAKOTE SPRINKLE
generic
Members ≥ 8 years of age will
require prior authorization.
DEPAKOTE
generic
Minimum age 2
INDERAL
CALAN
generic
generic
IR only
dimethyl fumarate
fingolimod
glatiramer acetate
interferon beta-1a
interferon beta-1a
teriflunomide
TECFIDERA
GILENYA
COPAXONE
AVONEX/AVONEX PEN
REBIF
AUBAGIO
brand
brand
brand
brand
brand
brand
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
PA, QL, SP
pyridostigmine
pyridostigmine
pyridostigmine
extended-release
MESTINON
MESTINON
generic
brand
tabs
syrup
MESTINON TIMESPAN
generic
amantadine
benztropine
carbidopa/levodopa
carbidopa/levodopa
extended-release
entacapone
pramipexole
ropinirole
selegiline
tolcapone
trihexyphenidyl
SYMMETREL
COGENTIN
SINEMET
generic
generic
generic
SINEMET CR
generic
COMTAN
MIRAPEX
REQUIP
ELDEPRYL
TASMAR
ARTANE
generic
generic
generic
generic
generic
generic
carbamazepine
carbamazepine
extended-release
clobazam
clonazepam
diazepam
divalproex sodium
cap sprinkle
divalproex sodium
delayed-release
TEGRETOL
CARBATROL
generic
Multiple Sclerosis
Myasthenia Gravis
Parkinson’s Disease
Seizures
tabs
generic
TEGRETOL-XR
ONFI
KLONOPIN
DIASTAT ACUDIAL
brand
generic
generic
DEPAKOTE SPRINKLE
generic
DEPAKOTE
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
except tabs
ST = Step Therapy
SP = Specialty Pharmacy
14
tablets*
tabs
rectal gel, QL
Members ≥ 8 years of age will
require prior authorization.
Minimum age 2
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
ethosuximide
ezogabine
felbamate
ZARONTIN
POTIGA
FELBATOL
Covered
Drug
generic
brand
generic
felbamate oral susp
FELBATOL ORAL SUSP
generic
gabapentin
lacosamide
lamotrigine
NEURONTIN
VIMPAT
LAMICTAL
generic
brand
generic
lamotrigine chew
dispersable tab
LAMICTAL CD CHEW TAB
generic
lamotrigine starter kit
LAMICTAL STARTER KIT
levetiracetam
KEPPRA (NOT XR)
methsuximide
CELONTIN
brand
oxcarbazepine
TRILEPTAL
generic
phenobarbital
phenytoin
phenytoin sodium
extended
pregabalin
pregabalin
primidone
rufinamide
PHENOBARBITAL
DILANTIN INFATABS
DILANTIN
generic
generic
tiagabine
GABITRIL
generic
tiagabine
GABITRIL
brand
topiramate
TOPAMAX
generic
topiramate sprinkle caps
TOPAMAX SPRINKLE
generic
valproic acid
vigabatrin oral solution
zonisamide
DEPAKENE
SABRIL SOLUTION
ZONEGRAN
generic
brand
generic
tetrabenazine
XENAZINE
brand
PA, SP
ACCUTANE
generic
PA
Miscellaneous
brand
generic
Requirements & Limits
Age Limits Apply
Members ≥ 8 years of age will
require prior authorization.
caps and tabs only
Age Limits Apply*
not chewable, QL
Members ≥ 8 years of age will
require prior authorization.
QL, Maximum age of 9
for solution
QL, Maximum age of 9
for suspension
generic
PHENYTEK
LYRICA
LYRICA SOLUTION
MYSOLINE
BANZEL
brand
brand
generic
brand
PA
oral solution, PA
tablets only, QL
Age Limits Apply,
2mg & 4mg*
Age Limits Apply,
12mg & 16mg*
QL
QL, Members ≥ 8 years of age
will require prior authorization.
PA, SP
QL
Dermatology
Acne Vulgaris
Oral
isotretinoin
Topical
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
15
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
azelaic acid
benzoyl peroxide
clindamycin
clindamycin
clindamycin
erythromycin
erythromycin
erythromycin/benzoyl
peroxide
FINACEA
BENZAC AC
CLEOCIN T
CLEOCIN T
CLEOCIN T
ERYGEL
T-STAT
BENZAMYCIN
salicylic acid
sulfacetamide/sulfur
sulfacetamide sodium
lotion
sulfacetamide/sulfur
tretinoin
Bacterial Infections
Covered
Drug
brand
generic
generic
generic
generic
generic
generic
Requirements & Limits
gel
gel
lotion
soln
gel 2%
soln
generic
NEUTROGENA OIL FREE
ACNE WASH
SULFACET-R
generic
liquid 2%, OTC
generic
lotion
KLARON
generic
PLEXION
ATRALIN
generic
AVITA
generic
RETIN-A
bacitracin
gentamicin
mupirocin
neomycin/polymyxin B/
bacitracin
silver sulfadiazine
BACITRACIN
GENTAK
BACTROBAN
generic
generic
generic
ointment, 22 gram tube only
NEOSPORIN
generic
OTC
SILVADENE
generic
alclometasone
ACLOVATE
DERMA-SMOOTHE
OIL/FS
SYNALAR
CORTIZONE
HYTONE
HYTONE
CORTIZONE-10 INTENSIVE
HEALING
generic
0.05% crm/oint
generic
oil 0.01%
generic
generic
generic
generic
soln/crm 0.01%
crm, oint, lot OTC
crm 0.5%, 1%, & 2.5%
lotion 1% & 2.5%
generic
crm 0.5% & 1%, OTC
BETA-VAL
SYNALAR
CORDRAN
CUTIVATE
LOCOID
generic
generic
brand
generic
generic
crm/oint/lotion 0.1%
crm, oint 0.025%
tape
crm 0.05%, oint 0.005%
crm/oint/soln 0.1%
Corticosteroids
Low Potency
fluocinolone acetonide
fluocinolone acetonide
hydrocortisone
hydrocortisone
hydrocortisone
hydrocortisone/aloe
Medium Potency
betamethasone val
fluocinolone acetonide
flurandrenolide
fluticasone propionate
hydrocortisone butyrate
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
16
OTC
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
hydrocortisone valerate
mometasone furoate
prednicarbate
triamcinolone acetonide
triamcinolone acetonide
WESTCORT
ELOCON
DERMATOP
KENALOG
KENALOG
Covered
Drug
generic
generic
generic
generic
generic
DIPROLENE
generic
lotion 0.05%
DIPROLENE AF
generic
crm 0.05%
generic
crm/lotion/oint 0.05%
LIDEX
generic
crm/oint/gel/soln 0.05%
LIDEX E
generic
crm 0.05%
KENALOG
generic
crm 0.5%
DIPROLENE
generic
gel 0.05%
DIPROLENE
generic
oint 0.05%
TEMOVATE
ULTRAVATE
generic
generic
crm/gel/oint/soln 0.05%
cream
ciclopirox
clotrimazole
clotrimazole
clotrimazole with
betamethasone
ketoconazole
miconazole
miconazole
miconazole
nystatin
terbinafine
tolnaftate
PENLAC SOLUTION 8%
LOTRIMIN AF
MYCELEX
generic
generic
generic
OTC
LOTRISONE
generic
NIZORAL
DESENEX
MICATIN
MONISTAT-DERM
MYCOSTATIN
LAMISIL AT
TINACTIN
generic
generic
generic
generic
generic
generic
generic
acitretin
calcipotriene
calcitriol
salicylic acid
SORIATANE
DOVONEX
VECTICAL
SCALPICIN
generic
generic
generic
generic
High Potency
betamethasone
augmented dip
betamethasone
augmented dip
betamethasone
dipropionate
fluocinonide
fluocinonide emulsified
base
triamcinolone acetonide
Very High Potency
betamethasone dip
augmented
betamethasone dip
augmented
clobetasol propionate
halobetasol
Fungal Infections
Psoriasis
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
17
Requirements & Limits
crm 0.2%
crm/oint/soln 0.1%
crm 0.1%
crm/lot/oint 0.025%
crm/oint/lotion 0.1%
2% OTC
OTC
OTC
OTC
oral caps, PA
ST
liquid 3%
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Rosacea
Brand Drug Name
brimonidine
MIRVASO
METROCREAM
metronidazole
METROGEL
Covered
Drug
Requirements & Limits
brand
PA
generic
METROLOTION
Scabies and Pediculosis
crotamiton
malathion
permethrin
permethrin
pyrethrins/piperonyl but.
Viral Infections
podofilox
salicylic acid 17%/
collodion
EURAX
OVIDE
ELIMITE
NIX CREME RINSE
RID SHAMPOO/
BUTOXIDE SHAMPOO
brand
generic
generic
generic
QL
5%, QL
1%, OTC
generic
4% OTC
CONDYLOX SOL
generic
sol
DUOFILM
generic
OTC
brand
soln/cream, OTC
Miscellaneous
aluminum acetate
aluminum chloride
hexahydrate
ammonium lactate
ammonium lactate
becaplermin gel
calamine
collagenase oint
fluorouracil
fluorouracil
fluorouracil
hexachlorophene
hydrocortisone
imiquimod 5% cream
ketoconazole
lidocaine
lidocaine
lidocaine
lidocaine/prilocaine
nitroglycerin
HYPERCARE 20%
generic
LAC-HYDRIN
LACTINOL
REGRANEX
generic
generic
brand
brand
brand
generic
generic
brand
brand
SANTYL
CARAC
EFUDEX
FLUOROPLEX
PHISOHEX
PROCTOSOL HC
CREAM 2.5%
PROCTOZONE
CREAM-HC 2.5%
ANUSOL HC 2.5%
ALDARA
NIZORAL SHAMPOO
LIDAMANTEL
LMX-4
XYLOCAINE
EMLA
RECTIV
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
1% cream
generic
generic
generic
generic
generic
generic
generic
brand
ST = Step Therapy
SP = Specialty Pharmacy
18
crm 12%, lotion 5% & 12%
lotion 10%
PA
lotion/ointment, OTC
QL
0.5% cream
PA
shampoo 2%
3% cream
4% cream (15 gm tubes), QL
jelly 2%
2.5% cream
0.4% rectal ointment, PA
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
pimecrolimus
ELIDEL
brand
selenium sulfide
SELSUN
generic
tacrolimus
PROTOPIC 0.03%
generic
tacrolimus
PROTOPIC 0.1%
generic
urea 40%
UREA 40% LOTION
generic
cream QL, ST, Step therapy
is not required for members
ages 2-11; not covered for
members less than 2 years
of age
lotion 2.5%
ointment 0.03% ST, Step
therapy is not required for
members ages 2-11; not
covered for members less
than 2 years
of age
ointment 0.1%, ST
(minimum age 16)
lotion
VOSOL OTIC
generic
otic
DOMEBORO OTIC
generic
VOSOL HC OTIC
generic
BENZOTIC
DEBROX
generic
generic
6.5%, OTC
CIPRODEX
brand
PA
CORTISPORIN OTIC
generic
otic
FLOXIN OTIC
generic
Ear, Nose & Throat
Ear
acetic acid
acetic acid/
aluminum acetate
acetic acid/
hydrocortisone
benzocaine/antipyrine
carbamide peroxide
ciprofloxacin/
dexamethasone
neomycin/polymyxin B/
hydrocortisone
ofloxacin
Nose
Antihistamines - First Generation, Sedating
CHLOR-TRIMETON
ALLERGY
CHLOR-TRIMETON
chlorpheniramine maleate
SYRUP
clemastine
CLEMASTINE
cyproheptadine
CYPROHEPTADINE
diphenhydramine
diphenhydramine
BENADRYL
hydroxyzine HCL
ATARAX
hydroxyzine pamoate
VISTARIL
chlorpheniramine
extended-release
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
12 mg, OTC
generic
2 mg/5 ml, OTC
generic
generic
generic
generic
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
19
OTC
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Covered
Drug
Brand Drug Name
Antihistamines - Second Generation, Nonsedating
cetirizine
ZYRTEC
generic
cetirizine chew tab
ZYRTEC CHEWABLE TABLET
generic
levocetirizine
loratadine
XYZAL
ALAVERT
CLARITIN
Requirements & Limits
generic
OTC
OTC, Members ≥ 8 years
of age will require prior
authorization.
tabs
generic
OTC
Antihistamines - Others Antihistamine/Decongestant Combinations
azelastine
ASTELIN
generic
TRIOTANN
generic
ACTIFED
generic
OTC
brand
OTC
Antihistamine/Decongestant Combinations - First Generation
chlorpheniramine/
phenylephrine/
pyrilamine
chlorpheniramine/
pseudoephedrine
diphenhydraminephenylephrine soln
BENADRYL-D
spray
Antihistamine/Decongestant Combinations - Second Generation
cetirizine hydrochloride/
pseudoephedrine
hydrochloride
12 hours
extended-release
ZYRTEC-D
loratadine/
pseudoephedrine
extended-release
ALAVERT ALRG
TAB/SINUS
Nasal Steroids
generic
5 mg-120 mg tablet
generic
OTC
ALAVERT-D
ALLERGY/CONG
FLONASE
NASACORT ALLERGY
triamcinolone nasal spray
24 HOUR
fluticasone
Miscellaneous Nasal Decongestants
generic
brand
OTC
oxymetazoline
AFRIN
NEO-SYNEPHRINE
generic
OTC
phenylephrine
DIMEATAPP DRO
DECONGES
generic
OTC
NASALCROM
ATROVENT NASAL SPRAY
OCEAN NASAL SPRAY
generic
generic
generic
OTC
QL
OTC
Miscellaneous Nasal
cromolyn sodium
ipratropium nasal
saline nasal spray 0.65%
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
20
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Throat and Mouth
chlorhexidine gluconate
lidocaine viscous
pilocarpine
triamcinolone
Brand Drug Name
Covered
Drug
PERIDEX
XYLOCAINE
SALAGEN
KENALOG IN ORABASE
generic
generic
generic
generic
paste
DECADRON
FLORINEF
CORTEF
MEDROL
MEDROL
generic
generic
generic
generic
generic
brand
4mg, 8mg, 16mg, 32mg
2mg
generic
syrup
Requirements & Limits
Endocrinology
Adrenal Corticosteroids
cortisone acetate
dexamethasone
fludrocortisone
hydrocortisone
methylprednisolone
methylprednisolone
prednisolone
prednisolone
prednisolone sodium
phosphate
prednisone
Androgens
PRELONE
ORAPRED
generic
PEDIAPRED
DELTASONE
generic
testosterone cypionate
DEPO-TESTOSTERONE
generic
testosterone enanthate
DELATESTRYL
generic
testosterone gel
topical tube, packet,
and pump bottle
Vials only. Disposable
syringes not covered.
TESTOSTERONE 1% TOPICAL GEL
generic
PA
glucagon, human
recombinant
GLUCAGON
brand
QL
NOVOLOG
brand
QL, vials
NOVOLOG MIX 70/30
brand
QL, vials
LANTUS
brand
QL, ST, vials
TOUJEO SOLOSTAR
brand
NOVOLIN R
RELION R
HUMULIN N
NOVOLIN N
RELION N
brand
brand
brand
brand
brand
Diabetes Mellitus
Glucose Elevating Agents
Insulins
insulin aspart
insulin aspart
protamine 70%/
insulin aspart 30%
insulin glargine
insulin glargine
300 unit/ml
insulin human
insulin human
insulin isophane
insulin isophane human
insulin isophane human
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
21
OTC, QL, vials
OTC, QL, vials
OTC, QL, vials
OTC, QL, vials
OTC, QL, vials
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
insulin isophane human
70%/regular 30%
insulin isophane human
70%/regular 30%
insulin isophane/regular
insulin lisopro pro/lispro
insulin lisopro prot/lispro
insulin lispro
insulin regular
Covered
Drug
Requirements & Limits
NOVOLIN 70/30
brand
OTC, QL, vials
RELION 70/30
brand
OTC, QL, vials
HUMULIN 70/30
HUMALOG MIX 50/50
HUMALOG MIX 75/25
HUMALOG
HUMULIN R
brand
brand
brand
brand
brand
OTC, QL, vials
QL, vials
QL, vials
QL, vials
OTC, QL, vials
Brand Drug Name
Monitoring - Strips and Kits/Diabetic Supplies
ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI,
VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC)
brand
ONE TOUCH TEST STRIPS (ULTRA, VERIO)
brand
Oral Agents
acarbose
canagliflozin
canagliflozin/metformin
chlorpropamide
empagliflozin
empagliflozin/metformin
glimepiride
glipizide
glipizide extended-release
glipizide-metformin
glyburide
glyburide, micronized
linagliptin
linagliptin/metformin
metformin
metformin ER
metformin/glyburide
nateglinide
pioglitazone
pioglitazone/glimepiride
pioglitazone/metformin
pioglitazone/metformin ER
repaglinide
saxagliptin
saxagliptin/metformin
tolazamide
PRECOSE
INVOKANA
INVOKAMET
DIABINESE
JARDIANCE
SYNJARDY
AMARYL
GLUCOTROL
GLUCOTROL XL
METAGLIP
MICRONASE
GLYNASE
TRADJENTA
JENTADUETO
GLUCOPHAGE
GLUCOPHAGE ER
GLUCOVANCE
STARLIX
ACTOS
DUETACT
ACTOPLUSMET
ACTOPLUS MET XR
PRANDIN
ONGLYZA
KOMBIGLYZE
TOLINASE
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
brand
brand
generic
brand
brand
generic
generic
generic
generic
generic
generic
brand
brand
generic
generic
generic
generic
generic
generic
generic
brand
generic
brand
brand
generic
ST = Step Therapy
SP = Specialty Pharmacy
22
QL for insulin dependent or
pregnant members: allow
testing up to 6 times per day
QL for non-insulin dependent
members: allow
once daily testing
ST
ST
ST
ST
ST
ST
QL
ST
QL, ST
ST
ST
ST
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
tolbutamide
TOLBUTAMIDE
Covered
Drug
generic
albiglutide
liraglutide
pramlintide
TANZEUM
VICTOZA
SYMLINPEN 60
brand
brand
brand
ST
ST
PA
mecasermin
somatropin
INCRELEX
NUTROPIN AQ NUSPIN
brand
brand
PA, SP
PA, SP
alendronate
calcitonin-salmon
calcitonin-salmon
etidronate
raloxifene
teriparatide inj
FOSAMAX
MIACALCIN
FORTICAL
DIDRONEL
EVISTA
FORTEO
generic
generic
brand
generic
generic
brand
QL
nasal spray, QL
nasal spray, QL
levothyroxine
levothyroxine
liothyronine
liotrix
methimazole
propylthiouracil
LEVOXYL
SYNTHROID
CYTOMEL
THYROLAR
TAPAZOLE
PROPYLTHIOURACIL
generic
generic
generic
brand
generic
generic
asfotase alfa
cabergoline
cholic acid
desmopressin
desmopressin acetate inj
methylergonovine
mifepristone
pegvisomant
sapropterin
STRENSIQ
DOSTINEX
CHOLBAM
DDAVP
DDAVP
METHERGINE
KORLYM
SOMAVERT
KUVAN
KUVAN POWDER FOR SOLUTION
VISTOGARD
brand
generic
brand
generic
generic
generic
brand
brand
brand
LOMOTIL
IMODIUM A-D
LOPERAMIDE
Miscellaneous Antidiabetic Agents
Growth Stimulating Agents
Osteoporosis
Thyroid Disease
Miscellaneous
sapropterin powder
uridine
Requirements & Limits
PA, SP
PA, SP
PA, SP
QL
4 mcg/ml, PA
PA, SP
PA, SP
PA, SP
brand
PA, SP
brand
SP
generic
generic
generic
OTC
Gastrointestinal
Diarrhea
diphenoxylate/atropine
loperamide
loperamide
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
23
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Covered
Drug
Brand Drug Name
Emesis
aprepitant
EMEND
dronabinol
meclizine
metoclopramide
MARINOL
ANTIVERT
REGLAN
ZOFRAN
ondansetron
prochlorperazine
promethazine
trimethobenzamide
brand
generic
generic
generic
esomeprazole granules
famotidine
QL applies to 40 mg, 80 mg
and 80-125 mg
PA
generic
QL
generic
generic
generic
300 mg caps
brand
OTC
MAALOX
generic
OTC
MYLANTA
generic
OTC
TAGAMET
NEXIUM 24HR OTC
generic
brand
ZOFRAN ODT
COMPAZINE
PHENERGAN
TIGAN
Gastroesophageal Reflux Disease (Gerd)/Peptic Ulcers
alginic acid/sodium
bicarbonate
alumina/magnesia
alumina/magnesia/
simethicone
cimetidine
esomeprazole
Requirements & Limits
NEXIUM DELAYED
RELEASE PACKET
PEPCID
brand
generic
PEPCID AC
PA
Members ≥ 2 years
of age will require prior
authorization
OTC Pepcid AC 10 mg
and 20 mg also covered/
encouraged with written
prescription.
lansoprazole
PREVACID
generic
lansoprazole
delayed-release
PREVACID SOLUTAB
generic
orally disintegrating tabs,
Members ≥ 2 years
of age will require prior
authorization. QL
PRILOSEC
generic
Capsules only, QL
PROTONIX
ZANTAC
ZANTAC
CARAFATE
generic
generic
generic
generic
CARAFATE SUSPENSION
generic
omeprazole
delayed-release
pantoprazole
ranitidine
ranitidine syrup
sucralfate
sulcralfate
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
24
150 mg tabs
suspension, Members 10
years of age up to 65 years
of age will require prior
authorization.
*Available without PA for
participating Behavioral Health
Prescribers
Brand Drug Name
Covered
Drug
dicyclomine
glycopyrrolate
hyoscyamine sulfate
hyoscyamine sulfate
extended-release
BENTYL
ROBINUL
LEVSIN
generic
generic
generic
LEVSINEX
generic
balsalazide
budesonide
hydrocortisone
mesalamine
mesalamine extendedrelease
COLAZAL
ENTOCORT EC
COLOCORT
ROWASA
generic
generic
generic
generic
ASACOL HD
generic
mesalamine
extended-release
DELZICOL
Generic Drug Name
Gastrointestinal Spasm
Inflammatory Bowel Disease
mesalamine supp
olsalazine sodium
sulfasalazine
sulfasalazine
delayed-release
Requirements & Limits
tablets only
PA
enema
enema only
APRISO
brand
LIALDA
PENTASA
CANASA
DIPENTUM
AZULFIDINE
brand
brand
generic
AZULFIDINE EN-TABS
generic
Laxatives
casanthranol-docusate
sodium
docusate calcium plus
docusate potasssium
docusate sodium
docusate sodium
glycerin
lactulose
peg 3350/electrolytes
peg 3350/sodium
bicarbonate/sodium
chloride
peg 3350/sodium
bicarbonate/sodium
chloride/potassium
chloride
polyethylene glycol 3350
sennosides
generic
OTC
DOK
COLACE
GLYCERIN SUPPOSITORY
ENULOSE
COLYTE
generic
generic
generic
generic
generic
generic
generic
OTC
OTC
100 mg tabs only, OTC
OTC
suppository, OTC
TRILYTE
generic
NULYTELY
generic
MIRALAX
SENOKOT
generic
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
25
8.6 mg tab, OTC
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Pancreatic Enzymes
pancrelipase
Covered
Drug
Brand Drug Name
Requirements & Limits
CREON
CREON 3000 UNIT
brand
ZENPEP
Probiotic Supplementation
acidophilus
acidophilus
acidophilus/bifidus
acidophilus/citrus pectin
acidophilus/pectin
lactobacillus
probiotic product
Miscellaneous
ACIDOPHILUS XTRA
ACIDOPHILUS
ACIDOPHILUS/BIFIDUS
WAFER
ACIDOPHILUS/CITRUS
PECTIN
ACIDOPHILUS/PECTIN
FLORANEX
PROBIOTIC FORMULA
brand
brand
OTC
caps and tabs, OTC
generic
OTC
generic
tabs, OTC
generic
generic
brand
caps, OTC
chewable tabs, OTC
caps, OTC
PA
PA, SP
atropine sulfate
misoprostol
naloxegol
teduglutide
SAL-TROPINE
CYTOTEC
MOVANTIK
GATTEX
URSO
brand
generic
brand
brand
ursodiol
URSO FORTE
generic
ACTIGALL
Infectious Diseases
Anthelmintics
albendazole
ivermectin
praziquantel
Antibacterials
Antituberculosis Agents
aminosalicyclic acid
cycloserine
ethambutol
ethionamide
isoniazid
pyrazinamide
rifabutin
rifapin
rifapentine
ALBENZA
STROMECTOL
BILTRICIDE
brand
brand
brand
PASER
SEROMYCIN
MYAMBUTOL
TRECATOR
ISONIAZID
PYRAZINAMIDE
MYCOBUTIN
RIFADIN
PRIFTIN
brand
generic
generic
brand
generic
generic
generic
generic
brand
Cephalosporins - First Generation
cefadroxil
DURICEF
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
PA
generic
ST = Step Therapy
SP = Specialty Pharmacy
26
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
Covered
Drug
Requirements & Limits
cephalexin
KEFLEX
generic
tabs are not covered,
not 750 mg caps
Cephalosporins - Second Generation
cefaclor
cefprozil
cefuroxime axetil
cefuroxime axetil
CECLOR
CEFZIL
CEFTIN
CEFTIN
generic
generic
generic
brand
tabs
suspension
cefdinir
cefixime
OMNICEF
SUPRAX
generic
brand
400 mg caps only, QL
ciprofloxacin
levofloxacin
ofloxacin
CIPRO
LEVAQUIN
FLOXIN
generic
brand
generic
tablets only
tabs
azithromycin
clarithromycin
clarithromycin ER
erythromycin delayedrelease
erythromycin
delayed-release
erythromycin
ethylsuccinate
erythromycin stearate
erythromycin/sulfisoxazole
ZITHROMAX
BIAXIN
BIAXIN XL
generic
generic
generic
ERYC
generic
Cephalosporins - Third Generation
Fluoroquinolones
Macrolides
Penicillins
ERY-TAB
brand
E.E.S.
generic
ERYTHROCIN
PEDIAZOLE
generic
generic
amoxicillin
amoxicillin/clavulanate
ampicillin
dicloxacillin
penicillin VK
AMOXICILLIN CAPSULES
AND CHEWABLES
AMOXIL SUSP
AUGMENTIN
PRINCIPEN
DICLOXACILLIN
VEETIDS
sulfamethoxazole/
trimethoprim, DS
BACTRIM
BACTRIM DS
amoxicillin
Sulfonamides
Tetracyclines
generic
generic
generic
generic
generic
generic
Except 500 mg and 875 mg
film-coated tabs.
suspension
generic
VIBRAMYCIN
doxycycline monohydrate DOXYCYCLINE
MONOHYDRATE
minocycline
MINOCIN
tetracycline
SUMYCIN
doxycycline hyclate
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
QL
generic
generic
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
27
capsules
caps
*Available without PA for
participating Behavioral Health
Prescribers
Brand Drug Name
Covered
Drug
Requirements & Limits
vancomycin HCl
VANCOCIN HCL
generic
cap, ST
clotrimazole
fluconazole
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole
itraconazole
ketoconazole
nystatin
terbinafine
terbinafine
voriconazole
MYCELEX
DIFLUCAN
GRIFULVIN V
GRIS-PEG
SPORANOX
SPORANOX
NIZORAL
MYCOSTATIN
LAMISIL
LAMISIL AT SPRAY
VFEND
generic
generic
generic
generic
generic
brand
generic
generic
generic
brand
generic
troches
QL
cream only, QL
soln 1%, PA, OTC
PA
ganciclovir
valganciclovir
CYTOVENE
VALCYTE
generic
generic
tabs only
enfuvirtide
FUZEON KIT
brand
SP
adefovir
HEPSERA
generic
elbasvir/grazoprevir
ZEPATIER
brand
entecavir
interferon alfa-2b
lamivudine
peginterferon alfa-2a
peginterferon alfa-2a
BARACLUDE
INTRON A
EPIVIR HBV
PEGASYS
PEGASYS PROCLICK
REBETOL
brand
brand
brand
brand
brand
Generic Drug Name
Miscellaneous
Antifungals
Antivirals
Cytomegalovirus Treatment
Entry/Fusion Inhibitors
Hepatitis Treatment
ribavirin
COPEGUS
generic
caps, PA, QL
soln, PA, QL
PA, SP, preferred for
Genotypes 1 & 4
PA, SP
PA, SP
PA, SP
200 mg caps and tabs only,
PA, SP
PA, SP, preferred for
Genotype 2
PA, SP, preferred for
Genotypes 2, 3, 5, & 6
sofosbuvir
SOVALDI
brand
sofosbuvir/velpatasvir
EPCLUSA
brand
acyclovir
valacyclovir
ZOVIRAX
VALTREX
generic
generic
caps, tabs, suspension
amantadine
oseltamivir
rimantadine
zanamivir
SYMMETREL
TAMIFLU
FLUMADINE
RELENZA
generic
brand
generic
brand
except tabs
QL
Herpes Treatment
Influenza Treatment
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
28
QL
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Covered
Drug
Brand Drug Name
Requirements & Limits
Nucleoside Reverse Transcriptase Inhibitors and Combinations – Diagnosis Required
abacavir
abacavir/lamivudine
abacavir/lamivudine/
zidovudine
didanosine
didanosine
delayed-release
emtricitabine
emtricitabine/rilpivirine/
tenofovir
lamivudine
lamivudine/zidovudine
stavudine
zidovudine
ZIAGEN
EPZICOM
generic
brand
TRIZIVIR
generic
VIDEX
brand
VIDEX EC
generic
EMTRIVA
brand
COMPLERA
brand
EPIVIR
COMBIVIR
ZERIT
RETROVIR
generic
generic
generic
generic
Nucleoside/Nucleotide Reverse Transcriptase Inhibitor Combination – Diagnosis Required
cobicistat/elvitegravir/ emSTRIBILD
tricitabine/tenofovir
efavirenz/emtricitabine/
ATRIPLA
tenofovir
emtricitabine/tenofovir
TRUVADA
brand
PA
brand
brand
Nucleotide Analogues Nucleotide Reverse Transcriptase Inhibitor – Diagnosis Required
tenofovir
VIREAD
brand
atazanavir
brand
darunavir
fosamprenavir
indinavir
lopinavir/ritonavir
nelfinavir
ritonavir
saquinavir mesylate
tipranavir
REYATAZ
REYATAZ POWDER
PACKET
PREZISTA
LEXIVA
CRIXIVAN
KALETRA
VIRACEPT
NORVIR
INVIRASE
APTIVUS
delavirdine
efavirenz
nevirapine
nevirapine ER
rilpivirine
RESCRIPTOR
SUSTIVA
VIRAMUNE
VIRAMUNE XR
EDURANT
Protease Inhibitors – Diagnosis Required
atazanavir
brand
Reverse Transcriptase Inhibitors – Diagnosis Required
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
brand
brand
brand
brand
brand
brand
brand
brand
brand
generic
brand
brand
ST = Step Therapy
SP = Specialty Pharmacy
29
Members ≥ 8 years of age will
require prior authorization
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
elvitegravir/cobicistat/
emtricitabine/tenofovir GENVOYA
alafenamide fumarate
Covered
Drug
Requirements & Limits
brand
Diagnosis Required
brand
Diagnosis required
Miscellaneous
abacavir/dolutegravir/
lamivudine
atovaquone
bedaquiline
chloroquine phosphate
clindamycin
cobicistat
dapsone
darunavir/cobicistat
dolutegravir
etravirine
hydroxychloroquine
linezolid
maraviroc
mefloquine
metronidazole
neomycin sulfate
TRIUMEQ
MEPRON
SIRTURO
ARALEN
CLEOCIN
TYBOST
DAPSONE
PREZCOBIX
TIVICAY
INTELENCE
PLAQUENIL
ZYVOX
SELZENTRY
LARIAM
FLAGYL
generic
brand
generic
generic
brand
brand
brand
brand
brand
generic
generic
brand
generic
generic
brand
nitazoxanide suspension
ALINIA SUSPENSION
brand
nitazoxanide tablet
nitrofurantoin
extended-release
nitrofurantoin
macrocrystals
ALINIA
brand
nitrofurantoin susp
palivizumab
paromomycin
povidone-iodine
primaquine
pyrimethamine
raltegravir
raltegravir
MACROBID
generic
MACRODANTIN
generic
FURADANTIN SUSP
25 MG/5 ML
SYNAGIS
HUMATIN
generic
brand
generic
generic
generic
brand
brand
DARAPRIM
ISENTRESS
ISENTRESS CHEWABLE
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
ST = Step Therapy
SP = Specialty Pharmacy
30
150 mg and 300 mg only
Diagnosis required
Diagnosis required
Diagnosis required
Diagnosis required
PA
Diagnosis required
tabs only
Members ≥ 8 years of age will
require prior authorization.
PA
Members ≥ 8 years of age will
require prior authorization.
PA, SP
OTC
PA
Diagnosis required
Chewable tablet;
Diagnosis required
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Covered
Drug
Brand Drug Name
raltegravir susp
ISENTRESS SUSP
trimethoprim
TRIMETHOPRIM
brand
generic
Requirements & Limits
Members ≥ 2 years of
age will require prior
authorization; Diagnosis
Required
tabs only
Musculoskeletal
Arthritis
Disease Modifying Anti-Rheumatic Drugs
adalimumab
anakinra
auranofin
azathioprine
certolizumab pegol
etanercept
hydroxychloroquine
leflunomide
methotrexate
penicillamine
sulfasalazine
sulfasalazine
delayed-release
HUMIRA
KINERET
RIDAURA
IMURAN
CIMZIA
ENBREL
PLAQUENIL
ARAVA
acetaminophen
TYLENOL
BAYER
DEPEN TITRATABLE
AZULFIDINE
brand
brand
brand
generic
brand
brand
generic
generic
generic
brand
generic
AZULFIDINE EN-TABS
generic
NSAIDs and Other Analgesics
aspirin
capsaicin
celecoxib
ECOTRIN
diflunisal
etodolac
CELEBREX
VOLTAREN 1% TOPICAL
GEL
DOLOBID
LODINE
ibuprofen
ADVIL
diclofenac 1% gel
MOTRIN
INDOCIN
ORUDIS
MOBIC
RELAFEN
NAPROSYN
ENTERIC COATEDnaproxen delayed release
NAPROSYN
oxaprozin
DAYPRO
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
PA, SP
PA, SP
PA, SP
generic
OTC
generic
OTC
brand
generic
OTC
PA, QL
generic
PA
generic
generic
500 mg tabs only
IR only
tabs, chew tabs
and susp, OTC
tabs, chew tabs and susp
generic
ibuprofen
indomethacin
ketoprofen
meloxicam
nabumetone
naproxen
PA, SP
PA, SP
generic
generic
generic
generic
generic
generic
IR only
QL
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
31
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
piroxicam
sulindac
FELDENE
CLINORIL
Covered
Drug
generic
generic
allopurinol
colchicine
colchicine w/ probenecid
febuxostat
probenecid
ZYLOPRIM
MITIGARE
COLBENEMID
ULORIC
PROBENECID
generic
brand
generic
brand
generic
chlorzoxazone
cyclobenzaprine
methocarbamol
orphenadrine
extended-release
PARAFON FORTE DSC
FLEXERIL
ROBAXIN
generic
generic
generic
NORFLEX
generic
baclofen
dantrolene
diazepam
tizanidine
BACLOFEN
DANTRIUM
VALIUM
ZANAFLEX
generic
generic
generic
generic
QL
tabs only, QL
desogestrel/EE
norethindrone/EE
MIRCETTE
ORTHO-NOVUM 10/11
generic
generic
QL
QL
levonorgestrel
levonorgestrel
PLAN B
PLAN B ONE STEP
generic
generic
QL
1.5 mg tab
levonorgestrel/EE
SEASONALE
generic
QL
medroxyprogesterone
acetate
DEPO-PROVERA
generic
QL
Gout
Skeletal Muscle Relaxants
Muscle Spasm
Spasticity
Requirements & Limits
ST
QL
OB-GYN
Contraceptives
Biphasic
Emergency Contraception
Extended Cycle
Injectable
Intravaginal
etonogestrel/EE
NUVARING
ORTHO COIL
brand
ring, QL
ortho diaphragm
ORTHO FLAT
brand
QL
generic
generic
0.1/20, QL
1/20, QL
ORTHO FLEX
Monophasic - 20 mcg Estrogen
levonorgestrel/EE
ALESSE
norethindrone acetate/EE LOESTRIN 1/20
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
32
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
norethindrone acetate/EE/
LOESTRIN FE 1/20
iron
Monophasic - 30 mcg Estrogen
Covered
Drug
Requirements & Limits
generic
1/20, QL
desogestrel/EE
levonorgestrel/EE
norethindrone acetate/EE
norethindrone acetate/EE/
iron
norgestrel/EE
ORTHO-CEPT
NORDETTE
LOESTRIN 1.5/30
generic
generic
generic
0.15/30, QL
0.15/30, QL
1.5/30, QL
LOESTRIN FE 1.5/30
generic
1.5/30, QL
LO/OVRAL
generic
0.3/30, QL
ethynodiol diacetate/EE
norethindrone/EE
norethindrone/EE
norethindrone/EE
norgestimate/EE
ZOVIA 1/35
BALZIVA
MODICON
ORTHO-NOVUM 1/35
ORTHO-CYCLEN
generic
generic
generic
generic
generic
1/35, QL
0.4/35, QL
0.5/35, QL
1/35, QL
0.25/35, QL
ethynodiol diacetate/EE
norethindrone/EE
norethindrone/ME
norgestrel/EE
ZOVIA 1/50
OVCON 50
ORTHO-NOVUM 1/50
OVRAL
generic
generic
generic
generic
1/50, QL
1/50, QL
1/50, QL
0.5/50, QL
norethindrone
norgestrel
ORTHO MICRONOR
OVRETTE
generic
generic
norelgestromin/EE
ORTHO EVRA
generic
desogestrel/EE
levonorgestrel/EE
norethindrone/EE
norethindrone/EE
norgestimate/EE
CYCLESSA
TRIVORA
ORTHO-NOVUM 7/7/7
TRI-NORINYL
ORTHO TRI-CYCLEN
generic
generic
generic
generic
generic
danazol
DANOCRINE
generic
Monophasic - 35 mcg Estrogen
Monophasic - 50 mcg Estrogen
Progestin
Transdermal
Triphasic
Endometriosis
Hormone Therapy/Menopause
Estrogens - Injectable
estradiol cypionate
DEPO-ESTRADIOL
brand
estradiol
estrogens, conjugated
ESTRACE CRM
PREMARIN
brand
brand
estradiol
estrogens, conjugated
ESTRACE
PREMARIN
Estrogens - Intravaginal
Estrogens - Oral
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
QL
QL
QL
QL
Gender edits apply: for female
patients only.
crm
generic
brand
ST = Step Therapy
SP = Specialty Pharmacy
33
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
estrogens, conjugated,
synthetic A
estrogens, conjugated,
synthetic B
estropipate
Estrogens - Transdermal
estradiol
estradiol td
Estrogen/Progestin
Covered
Drug
Brand Drug Name
CENESTIN
brand
ENJUVIA
brand
OGEN
generic
CLIMARA
ALORA
generic
brand
estrogens, conjugated/me- PREMPHASE
droxyprogesterone
PREMPRO
Requirements & Limits
QL
patch
brand
Progestins
medroxyprogesterone
acetate
norethindrone acetate
progesterone inj
progesterone micronized
PROVERA
generic
AYGESTIN
PROGESTERONE INJ
PROMETRIUM
generic
generic
generic
fluconazole
metronidazole
DIFLUCAN
FLAGYL
generic
generic
QL
tabs
clotrimazole
clindamycin
clindamycin
GYNE-LOTRIMIN
CLEOCIN
CLEOCIN
METROGEL-VAGINAL
generic
brand
generic
OTC
supp
crm
Vaginal Infections
Oral
Vaginal
metronidazole
miconazole
miconazole
terconazole
Miscellaneous
conjugated estrogen/
bazedoxifene
methylergonovine
tranexamic acid
METROGEL 1%
MONISTAT
MONISTAT 3
TERAZOL 3/7
generic
generic
generic
generic
DUAVEE
OTC
brand
METHERGINE
LYSTEDA
generic
generic
OPTIVAR
CROLOM
ALAWAY OTC
generic
generic
brand
brand
PA
Ophthalmic
Allergy
azelastine
cromolyn sodium
ketotifen
naphazoline/antazoline
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
34
ST
QL
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
naphazoline/glycerin
naphazoline HCL
naphazoline/zinc sulfate
tetrahydrozoline/
zinc sulfate
Covered
Drug
Brand Drug Name
CLEAR EYES REDNESS
RELIEF
VASOCLEAR
VASOCLEAR A
VISINE-AC
Requirements & Limits
generic
generic
generic
soln 0.02%
generic
Anti-Inflammatories
Anti-Infective/Anti-Inflammatory Combinations
gentamicin/prednisolone
acetate
neomycin/polymyxin B/
dexamethasone
neomycin/polymyxin B/
hydrocortisone
sulfacetamide/pred phos
tobramycin/
dexamethasone
PRED-G
brand
MAXITROL
generic
CORTISPORIN
generic
VASOCIDIN
generic
TOBRADEX
generic
VOLTAREN
OCUFEN
ACULAR/ACULAR LS
generic
generic
generic
DEXASOL
generic
soln 0.1%
FML
FML FORTE
FML LIQUIFILM
PRED FORTE
PRED MILD
INFLAMASE FORTE
VEXOL
brand
brand
generic
generic
brand
generic
brand
oint 0.1%
susp 0.25%
susp 0.1%
1%
0.12%
1%
carteolol
levobunolol
metipranolol
timolol
timolol maleate
BETAGAN
OPTIPRANOLOL
TIMOPTIC XE
TIMOPTIC
generic
generic
generic
generic
generic
0.3% ophthalmic solution
ophthalmic solution
0.3% ophthalmic solution
gel forming solution
dorzolamide
TRUSOPT
generic
dorzolamide/
timolol maleate
COSOPT
generic
Nonsteroidal
diclofenac sodium
flurbiprofen
ketorolac
Steroidal
dexamethasone sodium
phosphate
fluorometholone
fluorometholone
fluorometholone
prednisolone acetate
prednisolone acetate
prednisolone phosphate
rimexolone
Glaucoma
Beta-Blockers
Carbonic Anhydrase Inhibitors
10%/0.25%
Carbonic Anhydrase Inhibitor/Beta-Blocker Combination
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
35
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Cholinesterase Inhibitor
Covered
Drug
Brand Drug Name
ecothiophate
PHOSPHOLINE IODINE
brand
atropine
cyclopentolate
homatropine
scopolamine
ISOPTO ATROPINE
CYCLOGYL
ISOPTO HOMATROPINE
ISOPTO HYOSCINE
generic
generic
generic
brand
acetazolamide
acetazolamide
extended-release
methazolamide
ACETAZOLAMIDE
generic
DIAMOX SEQUELS
generic
NEPTAZANE
generic
latanoprost
XALATAN
generic
pilocarpine
pilocarpine
PILOPINE HS GEL
ISOPTO CARPINE
brand
generic
brimonidine
brimonidine
brimonidine
ALPHAGAN P
ALPHAGAN P
ALPHAGAN
brand
generic
generic
CILOXAN
ERYTHROMYCIN
ZYMAR
GENTAK
generic
generic
generic
brand
generic
NEOSPORIN
generic
OCUFLOX
POLYSPORIN
POLYTRIM
BLEPH-10
generic
generic
generic
generic
Mydriatics
Oral
Prostaglandins
Topical - Parasympathomimetics
Topical - Sympathomimetics
Infections
Bacterial
bacitracin
ciprofloxacin
erythromycin
gatifloxin
gentamicin
neomycin/polymyxin B/
gramicidin
ofloxacin
polymyxin B/bacitracin
polymyxin B/trimethoprim
sulfacetamide
sulfacetamide/
phenylephrine
tobramycin
VASOSULF
generic
trifluridine
VIROPTIC
generic
cysteamine 0.44%
ophthalmic solution
CYSTARAN
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
QL
0.1%
0.15%
0.2%
PA
oint/soln
brand
TOBREX
Viral
Requirements & Limits
brand
ST = Step Therapy
SP = Specialty Pharmacy
36
PA, SP
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
sodium chloride
MURO 128
hypertonic
sodium chloride
ALTACHLORE
hypertonic ophth soln
tetracaine hcl ophth soln ALTACAINE
Covered
Drug
Requirements & Limits
generic
soln 5%
generic
OTC
generic
Psychiatric
Alcohol Deterrents
acamprosate
disulfiram
naltrexone
CAMPRAL
ANTABUSE
REVIA
brand
generic
generic
alprazolam
chlordiazepoxide
clonazepam
clorazepate
diazepam
lorazepam
oxazepam
XANAX
LIBRIUM
KLONOPIN
TRANXENE
VALIUM
ATIVAN
SERAX
generic
generic
generic
generic
generic
generic
generic
buspirone
clomipramine
fluvoxamine
BUSPAR
ANAFRANIL
LUVOX
generic
generic
generic
ADDERALL
generic
Age Limits Apply, QL
brand
Age Limits Apply, QL
FOCALIN
DEXTROSTAT
INTUNIV
VYVANSE
generic
brand
generic
brand
Age Limits Apply
Age Limits Apply, QL
methylphenidate
RITALIN
generic
methylphenidate
extended-release
CONCERTA
generic
Anxiety
Benzodiazepines
Miscellaneous
Attention Deficit Hyperactivity Disorder (ADHD)
amphetamine/
dextroamphetamine
mixed salts
amphetamine/
dextroamphetamine
mixed salts
extended-release
dexmethylphenidate
dextroamphetamine
guanfacine ER
lisdexamfetamine
ADDERALL XR
(BRAND ADDERALL XR
IS PREFERRED)
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
37
QL, IR only
not wafers
QL
QL
QL
Age Limits Apply, QL
Age Limits Apply,
tabs only, QL
Age Limits Apply, QL
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
methylphenidate
extended-release
Bipolar Disorder
divalproex sodium
cap sprinkle
divalproex sodium
delayed-release
lithium carbonate
lithium carbonate
extended-release
Covered
Drug
Requirements & Limits
generic
Age Limits Apply, QL
DEPAKOTE SPRINKLE
generic
Members ≥ 8 years of age will
require prior authorization.
DEPAKOTE
generic
Minimum age 2
LITHIUM CARBONATE
ESKALITH CR
generic
Brand Drug Name
METADATE ER
RITALIN-SR
RITALIN LA
LITHOBID
Depression*
Monoamine Oxidase Inhibitor (MAOI)
generic
tranylcypromine
PARNATE
generic
citalopram
escitalopram
CELEXA
LEXAPRO
generic
generic
fluoxetine
PROZAC
generic
paroxetine
sertraline
PAXIL
ZOLOFT
generic
generic
QL
tablets, QL
10 mg and 20 mg caps and
20 mg soln only
QL
tablets, QL
duloxetine
venlafaxine
venlafaxine XR
CYMBALTA
EFFEXOR
EFFEXOR XR
generic
generic
generic
QL
QL
QL
amitriptyline
amoxapine
desipramine
doxepin
imipramine HCL
nortriptyline
ELAVIL
generic
generic
generic
generic
generic
generic
tablets
Selective Serotonin Reuptake Inhibitor (SSRIs)
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Tricyclic Antidepressants (TCAs)
NORPRAMIN
SINEQUAN
TOFRANIL
PAMELOR
Tricyclic Antidepressant/Phenothiazine Combination
amitriptyline/perphenazine TRIAVIL
Miscellaneous Agents
bupropion
bupropion
extended-release
bupropion
extended-release
chlordiazepoxideamitriptyline
tablets
generic
WELLBUTRIN
generic
WELLBUTRIN SR
generic
QL
WELLBUTRIN XL
generic
150 mg and 300 mg
LIMBITROL
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
38
*Available without PA for
participating Behavioral Health
Prescribers
LUDIOMIL
REMERON
SERZONE
DESYREL
Covered
Drug
generic
generic
generic
generic
50mg, 100mg, 150mg only
estazolam
flurazepam
temazepam
triazolam
PROSOM
DALMANE
RESTORIL
HALCION
generic
generic
generic
generic
QL
QL
QL
chloral hydrate
diphenhydramine
zaleplon
zolpidem
CHLORAL HYDRATE
NYTOL QUICK CAPS
SONATA
AMBIEN
generic
generic
generic
generic
OTC
QL
QL
Generic Drug Name
Brand Drug Name
maprotiline
mirtazapine
nefazodone hcl
trazodone
Insomnia
Benzodiazepines
Non-Benzodiazepines
Requirements & Limits
tabs (not soltabs)
Medications Coverable for Participating Behavioral Health Prescribers±
apomorphine
hydrochloride inj
aripiprazole lauroxil IM ER
susp
aripiprazole ODT
aripiprazole oral solution
asenapine maleate
sublingual
brexpiprazole
bupropion HCL tab SR
24HR
bupropion hydrobromide
carbamazepine
(antipsychotic) cap
SR 12HR
cariprazine
chlorpromazine hcl inj
clozapine
clozapine ODT
clozapine susp
desvenlafaxine fumarate
tab SR 24HR
desvenlafaxine succinate
tab SR 24HR
APOKYN
brand
ARISTADA
brand
ABILIFY DISCMELT
ABILIFY SOLUTION
brand
brand
Age Limits Apply
Age Limits Apply
SAPHRIS
brand
Age Limits Apply
REXULTI
brand
FORFIVO XL
brand
APLENZIN
brand
EQUETRO
brand
VRAYLAR
THORAZINE INJ
CLOZARIL
FAZACLO
VERSACLOZ
DESVENLAFAXINE
FUMARATE TAB
SR 24HR
brand
generic
generic
generic
brand
PRISTIQ
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
200 mg, Age Limits Apply
Age Limits Apply
generic
ST = Step Therapy
SP = Specialty Pharmacy
39
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
desvenlafaxine tab SR
24HR
duloxetine
escitalopram oxalate soln
escitalopram & methylfolate-B12-B6-D cap thpk
fluoxetine capsule
fluoxetine HCL cap
delayed release 90 mg
fluvoxamine maleate cap
SR 24HR
fluoxetine tablet
iloperidone
imipramine pamoate
isocarboxazid
levomilnacipran
loxapine aerosol powder
breath activated
lurasidone
metreleptin
mirtazapine ODT
olanzapine for IM inj
olanzapine-fluoxetine
olanzapine ODT
olanzapine pamoate for
extended rel IM sus
paliperidone tab SR 24HR
paroxetine HCL tab SR
24HR
paroxetine mesylate tab
phenelzine
pimavanserin
protriptyline
quetiapine fumarate tab
SR 24HR
risperidone microspheres
for inj
risperidone ODT
selegiline td patch
tasimelteon
Brand Drug Name
Covered
Drug
KHEDEZLA
generic
IRENKA
LEXAPRO SOLUTION
generic
generic
PRAMLYTE
Requirements & Limits
brand
PROZAC
generic
PROZAC WEEKLY
generic
LUVOX CR
generic
FLUOXETINE
FANAPT
TOFRANIL-PM
MARPLAN
FETZIMA
generic
brand
generic
brand
brand
ADASUVE
40mg
Age Limits Apply
brand
LATUDA
MYALEPT
REMERON SOLTAB
ZYPREXA
SYMBYAX
ZYPREXA ZYDIS
brand
brand
generic
generic
generic
generic
ZYPREXA RELPREVV
Age Limits Apply
injectable
Age Limits Apply
Age Limits Apply
brand
INVEGA
generic
PAXIL CR
generic
PEXEVA
NARDIL
NUPLAZID
VIVACTIL
brand
generic
brand
generic
Age Limits Apply
SEROQUEL XR
brand
Age Limits Apply
RISPERDAL CONSTA
brand
Age Limits Apply
generic
brand
brand
Age Limits Apply
RISPERDAL M-TAB
EMSAM
HETLIOZ
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
40
*Available without PA for
participating Behavioral Health
Prescribers
Covered
Drug
generic
brand
Generic Drug Name
Brand Drug Name
trazodone
trimipramine
venlafaxine HCL tab SR
24HR
vilazodone
vortioxetine
DESYREL
SURMONTIL
VENLAFAXINE HCL TAB SR
24HR
VIIBRYD
TRINTELLIX
buprenorphine
SUBUTEX
buprenorphine/naloxone
SUBOXONE
naloxone
naloxone
naltrexone
NALOXONE INJ
NARCAN NASAL SPRAY
REVIA
generic
brand
generic
aripiprazole
ABILIFY TABLETS
generic
aripiprazole ER injection
ABILIFY MAINTENA
clozapine
CLOZARIL
generic
dextromethorphan/
quinidine
NUEDEXTA
brand
olanzapine
ZYPREXA
generic
paliperidone
paliperidone
quetiapine
INVEGA SUSTENNA
INVEGA TRINZA
SEROQUEL
brand
brand
generic
risperidone
RISPERDAL
generic
risperidone
RISPERDAL CONSTA
risperidone oral soln
RISPERDAL SOLUTION
generic
ziprasidone
GEODON
generic
Age Limit Applies,
tablets, QL
Age Limit Applies, PA, QL
Age Limit Applies, PA
Age Limit Applies, QL
Age Limit Applies, QL, (Not
M-Tabs)
Age Limit Applies, PA, QL
QL, Members ≥ 8 years of age
will require prior authorization.
Age Limit Applies, QL
bupropion HCl
nicotine
nicotine polacrilex gum
nicotine polacrilex lozenge
varenicline
ZYBAN
NICODERM CQ
NICORETTE OTC
COMMITT OTC
CHANTIX
brand
generic
generic
generic
brand
patches, QL
QL
QL
QL
chlorpromazine
fluphenazine
fluphenazine decanoate
THORAZINE
PROLIXIN
PROLIXIN DECANOATE
generic
generic
generic
Narcotic Antagonists
Psychoses
Atypicals*
Smoking Cessation
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
300mg
generic
brand
brand
generic
brand
brand
brand
ST = Step Therapy
SP = Specialty Pharmacy
41
Requirements & Limits
PA, QL
2 mg and 8 mg film only,
PA, QL
QL
Age Limit Applies,
tablets, PA, QL
Age Limit Applies, PA, QL
25mg, 50mg, 100mg only,
Age Limit Applies, QL
PA
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
haloperidol
haloperidol decanoate
loxapine
perphenazine
pimozide
thioridazine
thiothixene
trifluoperazine
HALDOL
HALDOL DECANOATE
LOXITANE
TRILAFON
ORAP
MELLARIL
NAVANE
STELAZINE
Covered
Drug
generic
generic
generic
generic
generic
generic
generic
generic
Requirements & Limits
Respiratory Drugs
Antitussives, Decongestants, Expectorants And Combinations
benzonatate
brompheniramine &
phenylephrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan
brompheniramine/
pseudoephedrine/
dextromethorphan/
guaifenesin
TESSALON
DIMETAPP CLD ELX/
ALLERGY
generic
ACCUHIST DROPS
generic
generic
liquid
BROMFENEX PD CAP
DIMETAPP ELX
CLD/ALLE
generic
UNI-HIST DRO
CARDEC SYP
RONDEC SYRUP
generic
syrup
ACCUHIST PDX DROPS
generic
liquid
BROMALINE DM
generic
elixir
generic
syrup
generic
syrup
BROMFED DM
DALLERGY DM
CARBOFED
NEO DM
ANAPLEX DM
HISTACOL DM
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
42
± Available without PA for participating
Behavioral Health Prescribers,
otherwise PA required
Generic Drug Name
carbetapentane/
chlorpheniramine/
ephedrine/
phenylephrine
carbinoxamine/
pseudoephedrine
chlorphen-PEmethscopolamine
chlorphen tan/
carbetapentane tan
chlorphen tan/
pseudoeph tan
chlorphen tan/pyrilamine
tan/PE tan
chlorpheniramine/
dextromethorphan
Brand Drug Name
Covered
Drug
RYNATUSS
generic
RONDEC DROPS
generic
liquid
generic
syrup
TUSSI-12 S
generic
susp
TANAFED
generic
susp
TRIOTANN PEDIATRIC
SUSP
generic
susp
DURADRYL
QV-ALLERGY
R-TANNAMINE
ROBITUSSIN PED LIQ
CGH/COLD
ROBITUSSIN LIQ
CGH/CLD
generic
DIMETAPP SYP CGH/CLD
CORICIDIN TAB
CGH/CLD
chlorpheniramine maleate ED A-HIST TABLETS AND
phenylephrine HCL
LIQUID
RONDEC
DROPS
chlorpheniramine/
phenylephrine
CARDEC DRO
RONDEC SYRUP
chlorpheniramine/
phenylephrine
CARDEC SYP
HISTEX
chlorpheniramine/
pseudoephedrine
CPM/PSE
chlorpheniramine tan/
RYNATAN PEDIATRIC SUSP
phenylephrine tan
codeine/
DIHISTINE DH
chlorpheniramine/
PHENYLHIST LIQ DH
pseudoephedrine
GUIATUSS AC
codeine/guaifenesin
Requirements & Limits
GG/CODEINE
generic
generic
liquid
generic
syrup
generic
generic
susp
generic
generic
QL
M-CLEAR WC
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
43
± Available without PA for participating
Behavioral Health Prescribers,
otherwise PA required
Generic Drug Name
Covered
Drug
Brand Drug Name
codeine/guaifenesin/pseuGUIATUSS DAC
doephedrine
PROMETHAZINE
codeine/promethazine
W/CODEINE
codeine/promethazine/
PROMETHAZINE VC
phenylephrine
W/CODEINE
dextromethorphan/
brompheniramine/
BROMETANE DX
pseudoephedrine
dextromethorphan/
carbinoxamine/
CARDEC-DM
pseudoephedrine
dextromethorphanDURATUSS DM ELX
guaifenesin
GG/DM CR
dextromethorphan/
guaifenesin
dextromethorphanguaifenesin
dextromethorphan hbr
dextromethorphan
polistirex
extended-release
dextromethorphan/
promethazine
guaifenesin
guaifenesin
guaifenesin
extended-release
guaifenesin/
pseudoephedrine
guaifenesin/
pseudoephedrine/
dextromethorphan
guaifenesin/
pseudoephedrine
extended-release
MUCINEX DM
ROBITUSSIN DM
TUSSIN DM
ROBITUSSIN LIQ CGH/
CONG
ROBITUSSIN SYP MAX-ST
ROBITUSSIN PED SYP
DELSYM
PHENERGAN DM
PROMETHAZINE SYP DM
ROBITUSSIN
ROBITUSSIN SYP
CHST CNG
MUCINEX
ROBITUSSIN PE
PSE/GG
generic
generic
QL
generic
QL
generic
generic
drops
generic
soln 25-225 mg/5 ml
generic
OTC
generic
liq 10-200 mg/ 5 ml
generic
syrup
brand
OTC
generic
generic
OTC
generic
syrup 100 mg/5 ml
generic
OTC
generic
syrup, OTC
ROBITUSSIN CF
generic
GUAIFED
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
44
Requirements & Limits
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
guaifenesin/
pseudoephedrine
extended-release
GUAIFEN PSE
hydrocodone/
chlorpheniramine/
phenylephrine
hydrocodone/
guaifenesin
hydrocodone/
homatropine
loratadine &
pseudoephedrine SR
24hr
phenyleph/bromphen/
dextromethorphan/
guaifenesin
phenylephrine/
brompheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dextromethorphan
phenylephrine/
chlorpheniramine/
dihydrocodeine
phenylephrine/
dextromethorphan
MUCINEX D
Covered
Drug
Requirements & Limits
generic
OTC
GG/PSE CR
HISTUSSIN HC
generic
VITUSSIN
HYDROCODO/GG SYP
HYCODAN
HYDROMET SYP
HYDROCODONE/
TAB HOMATROP
generic
generic
ALLERGY/CONG TAB RELIEF
generic
ALLANHIST SYP PDX
generic
generic
QUAL-TUSSIN SYP DC
ATUSS DR
DE-CHLOR DM
tab 10-240 mg
OTC
generic
generic
syrup
generic
syrup
generic
liquid
RONDEC DM
STATUSS DM SYP
CARDEC DM SYP
MINUTUSS DR SYP
RONDEC DM DROPS
CARDEC DM DRO
ROBITUSSIN LIQ
CGH/ALRG
DIHYDRO-PE SYP
generic
DIMETAPP DRO
DCON/CGH
generic
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
45
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
phenylephrine/
dextromethorphan/
guaifenesin
phenylephrine/ephed/
CPM
w/carbetapentane
phenylephrine/guaifenesin
phenylephrine/
hydrocodone/
guaifenesin
phenylephrine/
pyrilamine/
dextromethorphan
phenylephrine/
pyrilamine
w/hydrocodone
phenylephrine tan/
pyrilamine tan/
carbeta tan
potassium iodide
promethazine &
phenylephrine
pseudoephedrine/
acetaminophen/
dextromethorphan
pseudoephedrine/
chlorpheniramine/
dextromethorphan
pseudoephedrine/
dextromethorphan/
guaifenesin
pseudoephedrine/
iburprofen
pseudoephedrine tan/
dexchlorphen tan/
DM tan
Brand Drug Name
Covered
Drug
ROBITUSSIN LIQ
CGH/CLD
generic
RYNATUSS PEDIATRIC
SUSP
generic
ROBITUSSIN LIQ
HD/CHST
generic
QUAL-TUSSIN SYP DC
generic
CODAL-DM
generic
CODIMAL DH
generic
syrup
TUSSI 12D S
generic
susp
brand
soln
generic
syrup 6.25-5 mg/ 5 mg
SSKI
PROMETH VC SYP
6.25-5/5
MAPAP COLD TAB
Requirements & Limits
susp
generic
PEDIACARE LIQ
MULTI-SY
ROBITUSSIN LIQ PED
NGHT
MULTI SYMPTOM TAB
COLD RLF
CHILD IBUPRO
SUS COLD
generic
generic
generic
IBUOROFEN TAB
COLD/SIN
TANAFED DMX
SUSPENSION
generic
susp
TRI-FED X
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
46
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
pyrilamine tan/phenyleph
RYNA-12 S
tan
TRIPROL/PSE SYP
tripolidine/
pseudoephedrine
APHEDRID TAB
Asthma/COPD
Inhalers - Beta Agonists
Covered
Drug
Requirements & Limits
generic
susp
generic
albuterol sulfate
indacaterol
olodaterol
VENTOLIN HFA
ARCAPTA NEOHALER
STRIVERDI RESPIMAT
brand
brand
brand
QL
fluticasone furoate
mometasone
mometasone inhalation
ARNUITY ELLIPTA
ASMANEX TWISTHALER
ASMANEX HFA
brand
brand
brand
QL
QL
QL
fluticasone/vilanterol
mometasone/formoterol
BREO ELLIPTA
DULERA
brand
brand
ST
ST
cromolyn
ipratropium/albuterol
ipratropium/albuterol
ipratropium HFA
nedocromil
omalizumab
umeclidinium inhalation
umeclidinium/vilanterol
INTAL
COMBIVENT
COMBIVENT RESPIMAT
ATROVENT HFA
TILADE
XOLAIR
INCRUSE ELLIPTA
ANORO ELLIPTA
brand
brand
brand
brand
brand
brand
brand
brand
QL
QL
inhaler
Inhalers - Corticosteroids
Inhalers - Corticosteroid/Beta Agonist Combinations
Inhalers - Others
Inhalers for Nebulization
albuterol
ACCUNEB
generic
albuterol
albuterol sulfate
PROVENTIL
ACCUNEB
generic
generic
budesonide
PULMICORT RESPULES
generic
cromolyn
ipratropium
ipratropium/albuterol
levalbuterol HCl
INTAL
ATROVENT
DUONEB
XOPENEX RESPULES
generic
generic
generic
generic
albuterol sulfate
metaproterenol
VOSPIRE ER
generic
METAPROTERENOL SYRUP generic
Oral Agents - Beta Agonists
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
47
PA, SP
0.63 mg/3 ml and 1.25 mg /3
ml, Covered for members less
than 8 years of age. Members
≥ 8 years of age will require
prior authorization.
soln 0.083%, 0.5%
soln nebu
susp, Members ≥ 5 years
of age will require prior
authorization. QL
soln, QL
soln, QL
soln
QL, ST
tab
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
terbutaline
BRETHINE
Covered
Drug
generic
montelukast
SINGULAIR
generic
QL
theophylline
theophylline
extended-release
theophylline
extended-release
theophylline
extended-release
theophylline
extended-release
THEOPHYLLINE
generic
liquid
brand
caps
THEOCHRON
generic
tabs
THEOPHYLLINE EXT-REL
generic
caps (12 hr)
UNIPHYL
generic
tabs
Oral Agents - Leukotriene Modifiers
Oral Agents - Theophylline
THEO-24
Requirements & Limits
Urological
Symptomatic Benign Prostatic Hypertrophy
alfuzosin ER
doxazosin
finasteride
tamsulosin
terazosin
Miscellaneous
UROXATRAL
CARDURA
PROSCAR
FLOMAX
HYTRIN
bethanechol
URECHOLINE
flavoxate hcl
FLAVOXATE
hyoscyamine,
methenamine,
phenyl salicylate,
UTIRA C
sodium phosphate
monobasic, methylene
blue
HIPREX
methenamine hippurate
UREX
oxybutynin chloride
DITROPAN XL
oxybutynin IR
DITROPAN
phenazopyridine
PYRIDIUM
potassium citrate
UROCIT-K
propantheline
sodium citrate/citric acid BICITRA
tolterodine
DETROL
trospium
SANCTURA
generic
generic
generic
generic
generic
generic
generic
brand
generic
generic
generic
generic
generic
generic
generic
generic
generic
QL, ST
generic
tab, OTC
ST
ST
Vitamins and Minerals
b-complex w/c & e
VI-STRESS
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
48
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name
b-complex w/c & e + zn
b-complex w/ c &
folic acid
b-complex w/minerals
calcitriol
BEC/ZINC
Covered
Drug
generic
EQL B COMPLEX
generic
tab, OTC
GERAVIM
ROCALTROL
generic
generic
liq, OTC
calcitriol oral soln
ROCALTROL SOLUTION
generic
calcium
OS-CAL
generic
cyanocobalamin
VITAMIN B-12
generic
electrolyte
PEDIALYTE
generic
ergocalciferol (D2)
DRISDOL
generic
NIFEREX
generic
caps, OTC
FEOSOL
GEL-KAM
generic
OTC
Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
ferrous bisglycinate/
polysaccarides iron
ferrous sulfate
LURIDE
fluoride
LURIDE LOZI-TABS
generic
PREVIDENT
PHOS-FLUR
folic acid
folic acid-vitamin
b6-vitamin b12
magnesium chloride
FOLIC ACID
generic
FABB
MAG64
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
tab, OTC
Members ≥ 8 years of age will
require prior authorization.
OTC
inj, Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
soln, oral, OTC
Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
brand
tab 2.2-25-1 mg, PA
generic
OTC
ST = Step Therapy
SP = Specialty Pharmacy
49
Requirements & Limits
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Covered
Drug
Brand Drug Name
magnesium oxide
MAG-OX
generic
multiple vitamin
THERA-PLUS
generic
multivitamins/
fluoride/±iron
POLY-VI-FLOR
generic
multivitamins/minerals
CENTRUM
generic
phytonadione
polysaccharide iron
complex
prenat-FE Bis-FE
prot succ-FA-CA
& omega 3
prenat-FE Bis-FE
prot succ-FA-CA
& omega 3
prenat-FE Bis-FE
prot succ-FA-CA
& omega 3
prenat-FE bis-FE
prot succ-FA-CA
& omega DR
prenat w/o A
w/fecbn-fegl-DSS-FA &
DHA
prenatal vit w/FE
bisglycinate
chelate-FA
MEPHYTON
brand
NIFEREX
generic
COMPLETE NATALCARE
PAK DHA
brand
TRUST NATALCARE
PAK DHA
brand
PRUET DHA PAK
SETONET PAK
brand
PRUET DHAEC PAK
brand
FOLTABS PAK PLUS DHA
RE OB + DHA PAK
brand
VITAPHIL
brand
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
50
Requirements & Limits
OTC, Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
liquid, OTC
Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
OTC, Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
elixir, OTC
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
prenatal vit w/FE
bisglycinate
chelate-FA
prenatal vit w/FE
bisglycinate
chelate-FA
prenatal vit w/FE
bisglyc-FE prot
succ-FA
prenatal vit w/FE
polysac cmplx-FA
prenatal vit w/iron
carbonyl-FA
prenatal vitamins
w/folic acid
Covered
Drug
Brand Drug Name
GENTEX ADE 28-1 MG
brand
VINATE AZ EX
brand
VINATE III
brand
EDGE OB CHW
brand
ATABEX PRENATAL
brand
Requirements & Limits
PRENATAL VITAMINS W/
FOLIC ACID
CENOGEN OB/ULTRA
MATERNA
generic
QL
NATALCARE
NESTABSCBF/FA/RX
prenatal w/o A w/FE
carbonyl-FE
gluc-DSS-FA
vitamin A
NIFEREX-PN FORTE
FOLTABS PRENATAL
TRI RX
brand
generic
vitamin ADC/fluoride/±iron
TRI-VI-FLOR
drops
generic
vitamin B complex/
vitamin C/folic acid
generic
NEPHROCAPS
vitamin B-1
vitamin B-6
vitamin C
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
generic
generic
ST = Step Therapy
SP = Specialty Pharmacy
51
OTC
Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
OTC
OTC
OTC
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Covered
Drug
generic
generic
Brand Drug Name
vitamin D
vitamin E
Requirements & Limits
OTC
OTC
members <3 years old,
OTC, Coverage for these
medications will be
determined by the member’s
individual benefits.
Please refer to individual
plan documents for coverage
information.
OTC
OTC, 220 mg
vitamins pediatric
TRI-VI-SOL
generic
zinc
zinc sulfate
ZINCATE
generic
generic
phosphorus
potassium acid phosphate
potassium bicarbonate/
potassium citrate
effervescent
potassium chloride ext-rel
K-PHOS NEUTRAL
K-PHOS ORIGINAL
generic
brand
tabs
K-LYTE
generic
tabs
MICRO-K 10
K-DUR 10
generic
caps
potassium chloride
extended-release
K-DUR 20
generic
tabs
generic
generic
brand
liquid
powder
brand
QL
brand
PA, SP
generic
brand
brand
PA, SP
PA, SP
brand
PA, SP
brand
PA, SP
Potassium
potassium chloride
potassium chloride
potassium iodide
KLOR-CON 8
KLOR-CON 10
POTASSIUM CHLORIDE
K-LOR
PIMA
Miscellaneous
Anaphylaxis
epinephrine
EPIPEN
EPIPEN JR.
TWINJECT
Cryopyrin — Associated Periodic Syndromes (CAPS)
canakinumab
ILARIS
acetylcysteine
aztreonam
dornase alfa
MUCOMYST
CAYSTON
PULMOZYME
KALYDECO
Cystic Fibrosis
ivacaftor
lumacaftor/ivacaftor
KALYDECO GRANULES
ORKAMBI
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
52
*Available without PA for
participating Behavioral Health
Prescribers
Covered
Drug
brand
Generic Drug Name
Brand Drug Name
tobramycin neb soln
BETHKIS
C1 Inhibitor, Human
icatibant
BERINERT
FIRAZYR
brand
brand
PA, SP
PA, SP
calcium acetate
cinacalcet
sevelamer
SENSIPAR
RENVELA
generic
brand
generic
667 mg tablet only
PA
ST
nintedanib
pirfenidone capsule
OFEV
ESBRIET
brand
brand
PA, SP
PA, SP
eltrombopag
PROMACTA
brand
PA, SP
Hereditary Angioedema
Hyperphosphatemia
Idiopathic Pulmonary Fibrosis (IPF)
Immune Thrombocytopenic Purpura
Medical Devices
Spacers
Metabolic Modifiers
CARBAGLU
RAVICTI
BUPHENYL ORAL
POWDER
diphtheria-tetanus tox adsorbed (dt) im
DIP/TET PED INJ
hepatitis a vaccine susp
PA, SP
QL
carglumic acid
glycerol phenylbutyrate
sodium phenylbutyrate
oral powder
Vaccine
Requirements & Limits
HAVRIX
VAQTA
hepatitis b vaccine (recom- ENGERIX-B
binant)
RECOMBIVAX HB
human papillomavirus
(hpv) 9-valent recomb GARDASIL 9
vac
human papillomavirus
(hpv) bival (type 16,
CERVARIX
18) recmb vac
human papillomavirus
(hpv) quadrivalent
GARDASIL
recombinant vac
influenza virus vaccine
recombinant hemag- FLUBLOK
glutinin (ha)
AFLURIA
influenza virus vaccine
split
FLUZONE SPLT
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
brand
brand
PA, SP
PA, SP
generic
PA
brand
QL
brand
QL
brand
QL
brand
QL
brand
QL
brand
QL
brand
QL
brand
QL
ST = Step Therapy
SP = Specialty Pharmacy
53
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
influenza virus vaccine
split high-dose pf
influenza virus vaccine
split pf
influenza virus vaccine
split quadrivalent
influenza virus vaccine tisscult subunit
influenza virus vaccine
types a&b surface
antigen
measles, mumps & rubella
virus vaccines for inj
meningococcal (a, c, y,
and w-135)
meningococcal (a, c, y,
and w-135) conjugate
vaccine
meningococcal (a, c, y,
and w-135) oligo conj
vac for inj
pneumococcal 13-valent
conjugate
pneumococcal vaccine
polyvalent
tet tox-diph-acell pertuss
ad
tetanus immune globulin
(human)
tetanus-diphtheria toxoids
(td)
typhoid vaccine
varicella virus vac live for
subcutaneous
zoster vaccine live
Miscellaneous
Covered
Drug
Requirements & Limits
FLUZONE HD PF
brand
QL
AFLURIA PF
brand
QL
brand
QL
FLUCELVAX
brand
QL
FLUVIRIN
brand
QL
M-M-R II
brand
QL
MENOMUNE
brand
QL
MENACTRA
brand
QL
MENVEO
brand
QL
PREVNAR 13
brand
QL
brand
QL
brand
QL
brand
QL
brand
QL
brand
capsules
VARIVAX
brand
QL
ZOSTAVAX
brand
QL, Age Limits Apply
Brand Drug Name
FLUARIX QUAD
FLULAVAL QUAD
FLUZONE QUAD
PNEUMOVAX
PNEUMOVAX 23
ADACEL
BOOSTRIX
HYPERTET S/D
TENIVAC
TET/DIP TOX INJ
VIVOTIF BERNA
sodium chloride irrigation
soln 0.9%
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
generic
ST = Step Therapy
SP = Specialty Pharmacy
54
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name Examples
OTC MEDICATIONS
The following is a list of OTC products on the PDL. Some OTC products are listed on the drug
list. OTC products covered are restricted to generics when available. Brand names are provided
as reference only.
Acne
CLEARASIL
SALAC
benzoyl peroxide crm, gel, lotion
salicylic acid lotion 2%
Antifungals
clotrimazole
MICATIN
miconazole crm, soln
LOTRIMIN AF
tolnaftate
TINACTIN
MONISTAT
vaginal products
GYNE-LOTRIMIN
Atopic Dermatitis
ALOE VESTA
BETACARE CREAM AND LOTION
dimethicone lotion 3%
CETAPHIL CREAM AND LOTION
DERMAPHOR OINTMENT
emollients
E-OINTMENT
GLYCERIN TOPICAL
Cough/Cold Allergy
CHLOR-TRIMETON
BENADRYL
CLARITIN
antihistamines
ALAVERT
ZYRTEC
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
55
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name Examples
Antihistamine/Decongestant Combinations
brompheniramine/pseudoephedrine
cetirizine/pseudoephedrine
chlorpheniramine/pseudoephedrine
DIMETAPP
ZYRTEC D
ACTIFED
ALAVERT ALRG TAB/SINUS
loratadine/pseudoephedrine
ALAVERT D
ALLERGY/CONG
Cough/Cold
ROBITUSSIN
antitussives
ROBITUSSIN DM
Age edit applied. Not covered for members under
the age 2.
ROBITUSSIN PE
ROBITUSSIN CF
DELSYM
NEO-SYNEPHRINE
AFRIN
nasal sprays
DIMETAPP DRO DECONGES
Diabetes
CURITY ALCOHOL PADS
GLUTOSE 15
alcohol swabs
glucose gel 40%
glucose oral tablets
HUMULIN
insulin (vials only)
NOVOLIN
Earwax Removal Products
carbamide peroxide
DEBROX
condoms
contraceptive foam
contraceptive gel
TROJAN
DELFEN
GYNOL II
Burow’s soln, wet dressings
dermatological baths
hydrocortisone crm, oint
DOMEBORO
COLLOIDAL OATMEAL BATHS
CORTAID
NEOSPORIN
topical antibacterials
MYCITRACIN
Family Planning
First Aid
BACITRACIN
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
56
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name Examples
Gastrointestinal
aluminum hydroxide gel susp (320 mg/5 ml only)
ALUMINUM HYDROXIDE
MYLANTA LIQUID
antacids liquids, chew tabs
MAALOX LIQUID
TUMS
IMODIUM A-D
antidiarrheals
KAOPECTATE
PEDIALYTE
PEPCID AC
FLEET ENEMA
DULCOLAX
electrolyte rehydrating soln
famotidine
laxative enemas
laxatives
FLEET PHOSPHO-SODA
MILK OF MAGNESIA
METAMUCIL
magnesium hydroxide susp
psyllium
rectal crm, suppositories
simethicone
stool softeners
sugar+orthophosphoric acid
KONSYL-D
PREPARATION H
MYLICON
COLACE
EMETROL
permethrin
piperonyl butoxide gel, liquid shampoo
NIX
PIPERONYL BUTOXIDE
dimenhydrinate
meclizine
DRAMAMINE
BONINE
allergic conjunctivitis
artificial tears
ALAWAY
HYPOTEARS
VISINE
decongestants
MURINE
Lice Products
Motion Sickness
Ophthalmics
NAPHCON A
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
57
*Available without PA for
participating Behavioral Health
Prescribers
Generic Drug Name
Brand Drug Name Examples
Pain
acetaminophen tabs, liquid,
drops, suppositories
TYLENOL
BAYER
aspirin tabs, EC. tabs
ECOTRIN
aspirin with buffers tabs
ADVIL
ibuprofen tabs, chew tabs and susp
MOTRIN IB
Smoking Cessation Products
COMMIT LOZENGES (QUANTITY LIMIT)
NICODERM CQ (QUANTITY LIMIT)
nicotine
NICOTINE GUM (QUANTITY LIMIT)
NICOTROL (QUANTITY LIMIT)
Vitamins/Minerals
OS-CAL
CALTRATE
calcium
TUMS
iron
ferrous fumarate, ferrous, gluconate,
errous sulfate, ferrous bis-glycinate
chelate and polysaccharide iron caps
iron polysaccharides
magnesium oxide
vitamin D 400 IU
FERGON
FEOSOL
NIFEREX
MAG-OX
VITAMIN D 400 IU
VI-DAYLIN
vitamins pediatric members <3 years old
POLY-VI-SOL
vitamins prenatal
TRI-VI-SOL
STUART PRENATAL
salicylic acid 17%/collodion
DUOFILM
fluoride dental rinse
PHOS-FLUR
Warts
Miscellaneous
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
58
*Available without PA for
participating Behavioral Health
Prescribers
Index of Covered Drugs
A
abacavir . . . . . . . . . . . . 29
abacavir/dolutegravir/
lamivudine . . . . . . . . . 30
abacavir/lamivudine . . . . . 29
abacavir/lamivudine/
zidovudine . . . . . . . . . 29
ABILIFY DISCMELT . . . . . . 39
ABILIFY MAINTENA . . . . . . 41
ABILIFY SOLUTION . . . . . . 39
ABILIFY TABLETS . . . . . . . 41
abiraterone . . . . . . . . . . . 5
acamprosate . . . . . . . . . 37
acarbose . . . . . . . . . . . . 22
ACCUHIST DROPS . . . . . . 42
ACCUHIST PDX DROPS . . . 42
ACCUNEB . . . . . . . . . . . 47
ACCUPRIL . . . . . . . . . . . .8
ACCURETIC . . . . . . . . . . .8
ACCUTANE . . . . . . . . . . 15
acebutalol . . . . . . . . . . . . 9
ACEON . . . . . . . . . . . . . .7
acetaminophen . . . . 12, 31, 58
acetazolamide . . . . . . . . . 36
ACETAZOLAMIDE . . . . . . . 36
acetazolamide
extended-release . . . . . 36
acetic acid . . . . . . . . . . . 19
acetic acid/aluminum acetate19
acetic acid/hydrocortisone . . 19
acetylcysteine . . . . . . . . . 52
acidophilus . . . . . . . . . . 26
ACIDOPHILUS . . . . . . . . . 26
acidophilus/bifidus . . . . . . 26
ACIDOPHILUS/BIFIDUS
WAFER . . . . . . . . . . . 26
acidophilus/citrus pectin . . . 26
ACIDOPHILUS/CITRUS
PECTIN . . . . . . . . . . . 26
acidophilus/pectin . . . . . . 26
ACIDOPHILUS/PECTIN . . . . 26
ACIDOPHILUS XTRA . . . . . 26
acitretin . . . . . . . . . . . . 17
ACLOVATE . . . . . . . . . . . 16
ACTIFED . . . . . . . . . . 20, 56
ACTIGALL . . . . . . . . . . . 26
ACTOPLUSMET . . . . . . . . 22
ACTOPLUS MET XR . . . . . 22
ACTOS . . . . . . . . . . . . . 22
ACULAR/ACULAR LS . . . . 35
acyclovir . . . . . . . . . . . . 28
ADACEL . . . . . . . . . . . . 54
ADALAT CC . . . . . . . . . . . 9
adalimumab . . . . . . . . . . 31
ADASUVE . . . . . . . . . . . 40
ADDERALL . . . . . . . . . . . 37
ADDERALL XR . . . . . . . . . 37
adefovir . . . . . . . . . . . . 28
ADEMPAS . . . . . . . . . . . 11
ADVIL . . . . . . . . . 12, 31, 58
afatinib . . . . . . . . . . . . . 4
AFINITOR . . . . . . . . . . . . .4
AFINITOR DISPERZ . . . . . . .4
AFLURIA . . . . . . . . . . . . 53
AFLURIA PF . . . . . . . . . . 54
AFRIN . . . . . . . . . . . 20, 56
AGRYLIN . . . . . . . . . . . . .7
ALAVERT . . . . . . . . . 20, 55
ALAVERT ALRG
TAB/SINUS . . . . . . 20, 56
ALAVERT D . . . . . . . . . . 56
ALAVERT-D . . . . . . . . . . . 20
ALAWAY . . . . . . . . . . . . 57
ALAWAY OTC . . . . . . . . . 34
albendazole . . . . . . . . . . 26
ALBENZA . . . . . . . . . . . . 26
albiglutide . . . . . . . . . . . 23
albuterol . . . . . . . . . . . . 47
albuterol sulfate . . . . . . . . 47
alclometasone . . . . . . . . 16
alcohol swabs . . . . . . . . . 56
ALDACTAZIDE . . . . . . . . . 10
ALDACTONE . . . . . . . . . . 10
ALDARA . . . . . . . . . . . . 18
ALDOMET . . . . . . . . . . . 11
ALDORIL . . . . . . . . . . . . 11
ALECENSA . . . . . . . . . . . .4
alectinib . . . . . . . . . . . . . 4
alendronate . . . . . . . . . . 23
ALL CAPS = Brand-name drug
Lower case = Generic drug
59
ALESSE . . . . . . . . . . . . . 32
alfuzosin ER . . . . . . . . . . 48
alginic acid/sodium
bicarbonate . . . . . . . . 24
ALINIA . . . . . . . . . . . . . 30
ALINIA SUSPENSION . . . . . 30
alirocumab . . . . . . . . . . 10
alitretinoin 1% gel . . . . . . . 6
ALKERAN . . . . . . . . . . . . 4
ALLANHIST SYP PDX . . . . . 45
allergic conjunctivitis . . . . . 57
ALLERGY/CONG . . . . 20, 56
ALLERGY/CONG
TAB RELIEF . . . . . . . . 45
allopurinol . . . . . . . . . . . 32
ALOE VESTA . . . . . . . . . . 55
ALORA . . . . . . . . . . . . . 34
ALPHAGAN . . . . . . . . . . 36
ALPHAGAN P . . . . . . . . . 36
alprazolam . . . . . . . . . . . 37
ALTACAINE . . . . . . . . . . . 37
ALTACHLORE . . . . . . . . . 37
altretamine . . . . . . . . . . . 4
alumina/magnesia . . . . . . 24
alumina/magnesia/
simethicone . . . . . . . . 24
aluminum acetate . . . . . . . 18
aluminum chloride
hexahydrate . . . . . . . . 18
ALUMINUM HYDROXIDE . . . 57
aluminum hydroxide gel susp 57
amantadine . . . . . . . . 14, 28
AMARYL . . . . . . . . . . . . 22
AMBIEN . . . . . . . . . . . . 39
ambrisentan . . . . . . . . . . 11
AMERGE . . . . . . . . . . . . 13
AMICAR . . . . . . . . . . . . . 7
amiloride . . . . . . . . . . . . 10
amiloride/hydrochlorothiazide10
aminocaproic acid . . . . . . . 7
aminosalicyclic acid . . . . . 26
amiodarone tabs . . . . . . . . 8
amitriptyline . . . . . . . . 14, 38
amitriptyline/perphenazine . 38
amlodipine . . . . . . . . . . . 9
Index of Covered Drugs
amlodipine-benazepril . . . . 10
ammonium lactate . . . . . . 18
amoxapine . . . . . . . . . . . 38
amoxicillin . . . . . . . . . . . 27
AMOXICILLIN CAPSULES
AND CHEWABLES . . . . 27
amoxicillin/clavulanate . . . . 27
AMOXIL SUSP . . . . . . . . . 27
amphetamine/dextroamphetamine mixed salts . . . . 37
amphetamine/dextroamphetamine mixed salts
extended-release . . . . . 37
ampicillin . . . . . . . . . . . 27
ANAFRANIL . . . . . . . . . . 37
anagrelide . . . . . . . . . . . 7
anakinra . . . . . . . . . . . . 31
ANAPLEX DM . . . . . . . . . 42
anastrozole . . . . . . . . . . . 5
ANORO ELLIPTA . . . . . . . 47
ANTABUSE . . . . . . . . . . . 37
antacids liquids, chew tabs . 57
antidiarrheals . . . . . . . . . 57
antihistamines . . . . . . . . . 55
antitussives . . . . . . . . . . 56
ANTIVERT . . . . . . . . . . . 24
ANUSOL HC 2.5% . . . . . . 18
APHEDRID TAB . . . . . . . . 47
apixaban . . . . . . . . . . . . 6
APLENZIN . . . . . . . . . . . 39
APOKYN . . . . . . . . . . . . 39
apomorphine
hydrochloride inj . . . . . 39
aprepitant . . . . . . . . . . . 24
APRESOLINE . . . . . . . . . 11
APRISO . . . . . . . . . . . . . 25
APTIVUS . . . . . . . . . . . . 29
ARALEN . . . . . . . . . . . . 30
ARANESP . . . . . . . . . . . . 7
ARAVA . . . . . . . . . . . . . 31
ARCAPTA NEOHALER . . . . 47
ARICEPT . . . . . . . . . 11, 12
ARIMIDEX . . . . . . . . . . . . 5
aripiprazole . . . . . . . . . . 41
aripiprazole ER injection . . . 41
aripiprazole lauroxil IM
ER susp . . . . . . . . . . 39
aripiprazole ODT . . . . . . . 39
aripiprazole oral solution . . . 39
ARISTADA . . . . . . . . . . . 39
ARNUITY ELLIPTA . . . . . . . 47
AROMASIN . . . . . . . . . . . .5
ARTANE . . . . . . . . . . . . 14
artificial tears . . . . . . . . . 57
ASACOL HD . . . . . . . . . . 25
asenapine maleate sublingual39
asfotase alfa . . . . . . . . . . 23
ASMANEX HFA . . . . . . . . 47
ASMANEX TWISTHALER . . . 47
aspirin . . . . . . . . . . . . 7, 31
aspirin/acetaminophen/
caffeine . . . . . . . . . . 12
aspirin tabs, EC. tabs . . . . . 58
aspirin with buffers tabs . . . 58
ASTELIN . . . . . . . . . . . . 20
ATABEX PRENATAL . . . . . . 51
ATARAX . . . . . . . . . . . . . 19
atazanavir . . . . . . . . . . . 29
atenolol . . . . . . . . . . . . . 9
atenolol/chlorthalidone . . . . 9
ATIVAN . . . . . . . . . . . . . 37
atorvastatin . . . . . . . . . . 10
atovaquone . . . . . . . . . . 30
ATRALIN . . . . . . . . . . . . 16
ATRIPLA . . . . . . . . . . . . 29
atropine . . . . . . . . . . . . 36
atropine sulfate . . . . . . . . 26
ATROVENT . . . . . . . . . . . 47
ATROVENT HFA . . . . . . . . 47
ATROVENT NASAL SPRAY . . 20
ATUSS DR . . . . . . . . . . . 45
AUBAGIO . . . . . . . . . . . . 14
AUGMENTIN . . . . . . . . . . 27
auranofin . . . . . . . . . . . 31
AVITA . . . . . . . . . . . . . . 16
AVONEX/AVONEX PEN . . . 14
axitinib . . . . . . . . . . . . . 4
AYGESTIN . . . . . . . . . . . 34
azathioprine . . . . . . . . 6, 31
azelaic acid . . . . . . . . . . 16
ALL CAPS = Brand-name drug
Lower case = Generic drug
60
azelastine . . . . . . . . . 20, 34
azithromycin . . . . . . . . . . 27
aztreonam . . . . . . . . . . . 52
AZULFIDINE . . . . . . . 25, 31
AZULFIDINE EN-TABS . . 25, 31
B
bacitracin . . . . . . . . . 16, 36
BACITRACIN . . . . . . . 16, 56
baclofen . . . . . . . . . . . . 32
BACLOFEN . . . . . . . . . . . 32
BACTRIM . . . . . . . . . . . . 27
BACTRIM DS . . . . . . . . . . 27
BACTROBAN . . . . . . . . . 16
balsalazide . . . . . . . . . . 25
BALZIVA . . . . . . . . . . . . 33
BANZEL . . . . . . . . . . . . 15
BARACLUDE . . . . . . . . . . 28
BAYER . . . . . . . . . 7, 31, 58
b-complex w/c & e . . . . . . 48
b-complex w/c & e + zn . . . 49
b-complex w/ c & folic acid . 49
b-complex w/minerals . . . . 49
becaplermin gel . . . . . . . . 18
BEC/ZINC . . . . . . . . . . . 49
bedaquiline . . . . . . . . . . 30
BENADRYL . . . . . . . . 19, 55
BENADRYL-D . . . . . . . . . 20
benazepril . . . . . . . . . . . .7
benazepril/hydrochlorothiazide8
BENTYL . . . . . . . . . . . . 25
BENZAC AC . . . . . . . . . . 16
BENZAMYCIN . . . . . . . . . 16
benzocaine/antipyrine . . . . 19
benzonatate . . . . . . . . . . 42
BENZOTIC . . . . . . . . . . . 19
benzoyl peroxide . . . . . 16, 55
benztropine . . . . . . . . . . 14
BERINERT . . . . . . . . . . . 53
BETACARE CREAM AND
LOTION . . . . . . . . . . . 55
BETAGAN . . . . . . . . . . . 35
betamethasone
augmented dip . . . . . . 17
betamethasone dipropionate 17
Index of Covered Drugs
betamethasone val . . . . . . 16
BETAPACE . . . . . . . . . . . .9
BETA-VAL . . . . . . . . . . . . 16
bethanechol . . . . . . . . . . 48
BETHKIS . . . . . . . . . . . . 53
bexarotene caps and
topical gel . . . . . . . . . . 6
BIAXIN . . . . . . . . . . . . . 27
BIAXIN XL . . . . . . . . . . . 27
bicalutamide . . . . . . . . . . 5
BICITRA . . . . . . . . . . . . 48
BILTRICIDE . . . . . . . . . . . 26
bisoprolol . . . . . . . . . . . . 9
bisoprolol/hydrochlorothiazide 9
BLEPH-10 . . . . . . . . . . . 36
BONINE . . . . . . . . . . . . 57
BOOSTRIX . . . . . . . . . . . 54
bosentan . . . . . . . . . . . 11
BOSULIF . . . . . . . . . . . . .4
bosutinib . . . . . . . . . . . . 4
BREO ELLIPTA . . . . . . . . . 47
BRETHINE . . . . . . . . . . . 48
brexpiprazole . . . . . . . . . 39
brimonidine . . . . . . . . 18, 36
BROMALINE DM . . . . . . . 42
BROMETANE DX . . . . . . . 44
BROMFED DM . . . . . . . . . 42
BROMFENEX PD CAP . . . . 42
brompheniramine &
phenylephrine . . . . . . . 42
brompheniramine/
pseudoephedrine . . 42, 56
brompheniramine/
pseudoephedrine/
dextromethorphan . . . . 42
brompheniramine/
pseudoephedrine/dextromethorphan/guaifenesin 42
budesonide . . . . . . . . 25, 47
bumetanide . . . . . . . . . . 10
BUMEX . . . . . . . . . . . . . 10
BUPHENYL ORAL POWDER 53
buprenorphine . . . . . . . . 41
buprenorphine/naloxone . . . 41
bupropion . . . . . . . . . . . 38
bupropion extended-release 38
bupropion HCl . . . . . . . . 41
bupropion HCL tab SR . . . 39
bupropion hydrobromide . . 39
Burow’s soln, wet dressings . 56
BUSPAR . . . . . . . . . . . . 37
buspirone . . . . . . . . . . . 37
busulfan . . . . . . . . . . . . . 4
butalbital/acetaminophen . . 12
butalbital/acetaminophen/
caffeine . . . . . . . . . . 12
butalbital/apap/caff/cod . . . 12
butalbital/asa/caff/cod . . . . 12
butalbital/aspirin/caffeine . . 12
butorphanol . . . . . . . . . . 13
C
C1 Inhibitor, Human . . . . . 53
cabergoline . . . . . . . . . . 23
cabozantinib . . . . . . . . . . 4
CAFERGOT . . . . . . . . . . 13
calamine . . . . . . . . . . . . 18
CALAN . . . . . . . . . . . 9, 14
CALAN SR . . . . . . . . . . . .9
calcipotriene . . . . . . . . . 17
calcitonin-salmon . . . . . . . 23
calcitriol . . . . . . . . . . 17, 49
calcium . . . . . . . . . . 49, 58
calcium acetate . . . . . . . . 53
CALTRATE . . . . . . . . . . . 58
CAMPRAL . . . . . . . . . . . 37
canagliflozin . . . . . . . . . . 22
canagliflozin/metformin . . . 22
canakinumab . . . . . . . . . 52
CANASA . . . . . . . . . . . . 25
capecitabine . . . . . . . . . . 4
CAPOTEN . . . . . . . . . . . . 7
CAPOZIDE . . . . . . . . . . . .8
CAPRELSA . . . . . . . . . . . .5
capsaicin . . . . . . . . . . . 31
captopril . . . . . . . . . . . . .7
captopril/hydrochlorothiazide . 8
CARAC . . . . . . . . . . . . . 18
CARAFATE . . . . . . . . . . . 24
CARAFATE SUSPENSION . . 24
ALL CAPS = Brand-name drug
Lower case = Generic drug
61
CARBAGLU . . . . . . . . . . 53
carbamazepine . . . . . . . . 14
carbamazepine cap SR . . . 39
carbamazepine
extended-release . . . . . 14
carbamide peroxide . . . 19, 56
CARBATROL . . . . . . . . . 14
carbetapentane/chlorpheniramine/ephedrine/
phenylephrine . . . . . . . 43
carbidopa/levodopa . . . . . 14
carbidopa/levodopa
extended-release . . . . . 14
carbinoxamine/
pseudoephedrine . . . . . 43
CARBOFED . . . . . . . . . . 42
CARDEC-DM . . . . . . . . . . 44
CARDEC DM DRO . . . . . . 45
CARDEC DM SYP . . . . . . . 45
CARDEC DRO . . . . . . . . . 43
CARDEC SYP . . . . . . . 42, 43
CARDENE . . . . . . . . . . . . 9
CARDIZEM . . . . . . . . . . . .9
CARDIZEM CD . . . . . . . . . .9
CARDIZEM SR . . . . . . . . . .9
CARDURA . . . . . . . . . 8, 48
carglumic acid . . . . . . . . 53
cariprazine . . . . . . . . . . . 39
carteolol . . . . . . . . . . . . 35
carvedilol . . . . . . . . . . . . 9
casanthranol-docusate
sodium . . . . . . . . . . 25
CASODEX . . . . . . . . . . . . 5
CATAPRES . . . . . . . . . . . .8
CATAPRES- TTS . . . . . . . . .8
CAYSTON . . . . . . . . . . . 52
CECLOR . . . . . . . . . . . . 27
cefaclor . . . . . . . . . . . . 27
cefadroxil . . . . . . . . . . . 26
cefdinir . . . . . . . . . . . . . 27
cefixime . . . . . . . . . . . . 27
cefprozil . . . . . . . . . . . . 27
CEFTIN . . . . . . . . . . . . . 27
cefuroxime axetil . . . . . . . 27
CEFZIL . . . . . . . . . . . . . 27
Index of Covered Drugs
CELEBREX . . . . . . . . . . . 31
celecoxib . . . . . . . . . . . 31
CELEXA . . . . . . . . . . . . 38
CELLCEPT . . . . . . . . . . . .6
CELONTIN . . . . . . . . . . . 15
CENESTIN . . . . . . . . . . . 34
CENOGEN OB/ULTRA . . . . 51
CENTRUM . . . . . . . . . . . 50
cephalexin . . . . . . . . . . . 27
ceritinib . . . . . . . . . . . . . 4
certolizumab pegol . . . . . . 31
CERVARIX . . . . . . . . . . . 53
CETAPHIL CREAM AND
LOTION . . . . . . . . . . . 55
cetirizine . . . . . . . . . . . . 20
cetirizine chew tab . . . . . . 20
cetirizine hydrochloride/pseudoephedrine hydrochloride
extended-release . . . . . 20
cetirizine/pseudoephedrine . 56
CHANTIX . . . . . . . . . . . . 41
CHILD IBUPRO SUS COLD . 46
chloral hydrate . . . . . . . . 39
CHLORAL HYDRATE . . . . . 39
chlorambucil . . . . . . . . . . 4
chlordiazepoxide . . . . . . . 37
chlordiazepoxideamitriptyline . . . . . . . . 38
chlorhexidine gluconate . . . 21
chloroquine phosphate . . . . 30
chlorothiazide . . . . . . . . . 10
chlorpheniramine/
dextromethorphan . . . . 43
chlorpheniramine
extended-release . . . . . 19
chlorpheniramine maleate . . 19
chlorpheniramine maleate
phenylephrine HCL . . . . 43
chlorpheniramine/
phenylephrine . . . . . . . 43
chlorpheniramine/phenylephrine/pyrilamine . . . . . . 20
chlorpheniramine/
pseudoephedrine 20, 43, 56
chlorpheniramine tan/
phenylephrine tan . . . . 43
chlorphen-PEmethscopolamine . . . . 43
chlorphen tan/
carbetapentane tan . . . . 43
chlorphen tan/
pseudoeph tan . . . . . . 43
chlorphen tan/pyrilamine tan/
PE tan . . . . . . . . . . . 43
chlorpromazine . . . . . . . . 41
chlorpromazine hcl inj . . . . 39
chlorpropamide . . . . . . . . 22
chlorthalidone . . . . . . . . . 10
CHLORTHALIDONE . . . . . . 10
CHLOR-TRIMETON . . . . . . 55
CHLOR-TRIMETON
ALLERGY . . . . . . . . . 19
CHLOR-TRIMETON SYRUP . 19
chlorzoxazone . . . . . . . . . 32
CHOLBAM . . . . . . . . . . . 23
cholestyramine . . . . . . . . 10
cholic acid . . . . . . . . . . . 23
ciclopirox . . . . . . . . . . . 17
cilostazol . . . . . . . . . . . . 7
CILOXAN . . . . . . . . . . . . 36
cimetidine . . . . . . . . . . . 24
CIMZIA . . . . . . . . . . . . . 31
cinacalcet . . . . . . . . . . . 53
CIPRO . . . . . . . . . . . . . 27
CIPRODEX . . . . . . . . . . . 19
ciprofloxacin . . . . . . . 27, 36
ciprofloxacin/dexamethasone19
citalopram . . . . . . . . . . . 38
clarithromycin . . . . . . . . . 27
clarithromycin ER . . . . . . . 27
CLARITIN . . . . . . . . . 20, 55
CLEARASIL . . . . . . . . . . 55
CLEAR EYES REDNESS
RELIEF . . . . . . . . . . . 35
clemastine . . . . . . . . . . . 19
CLEMASTINE . . . . . . . . . 19
CLEOCIN . . . . . . . . . 30, 34
CLEOCIN T . . . . . . . . . . . 16
CLIMARA . . . . . . . . . . . . 34
ALL CAPS = Brand-name drug
Lower case = Generic drug
62
clindamycin . . . . . . 16, 30, 34
CLINORIL . . . . . . . . . 12, 32
clobazam . . . . . . . . . . . 14
clobetasol propionate . . . . 17
clomipramine . . . . . . . . . 37
clonazepam . . . . . . . 14, 37
clonidine . . . . . . . . . . . . 8
clonidine transdermal . . . . . 8
clopidogrel . . . . . . . . . . . 7
clorazepate . . . . . . . . . . 37
clotrimazole . . . .17, 28, 34, 55
clotrimazole with
betamethasone . . . . . . 17
clozapine . . . . . . . . . 39, 41
clozapine ODT . . . . . . . . 39
clozapine susp . . . . . . . . 39
CLOZARIL . . . . . . . . . 39, 41
cobicistat . . . . . . . . . . . 30
cobicistat/elvitegravir/
emtricitabine/tenofovir . . 29
cobimetinib . . . . . . . . . . . 4
CODAL-DM . . . . . . . . . . . 46
codeine/acetaminophen . . . 13
codeine/chlorpheniramine/
pseudoephedrine . . . . . 43
codeine/guaifenesin . . . . . 43
codeine/guaifenesin/pseudoephedrine . . . . . . . . . 44
codeine/promethazine . . . . 44
codeine/promethazine/
phenylephrine . . . . . . . 44
codeine sulfate . . . . . . . . 13
CODIMAL DH . . . . . . . . . 46
COGENTIN . . . . . . . . . . . 14
COLACE . . . . . . . . . 25, 57
COLAZAL . . . . . . . . . . . 25
COLBENEMID . . . . . . . . . 32
colchicine . . . . . . . . . . . 32
colchicine w/ probenecid . . 32
collagenase oint . . . . . . . 18
COLLOIDAL OATMEAL
BATHS . . . . . . . . . . . 56
COLOCORT . . . . . . . . . . 25
COLYTE . . . . . . . . . . . . 25
COMBIVENT . . . . . . . . . . 47
Index of Covered Drugs
COMBIVENT RESPIMAT . . . 47
COMBIVIR . . . . . . . . . . . 29
COMETRIQ . . . . . . . . . . . 4
COMMIT LOZENGES . . . . . 58
COMMITT OTC . . . . . . . . 41
COMPAZINE . . . . . . . . . . 24
COMPLERA . . . . . . . . . . 29
COMPLETE NATALCARE
PAK DHA . . . . . . . . . . 50
COMTAN . . . . . . . . . . . . 14
CONCERTA . . . . . . . . . . 37
condoms . . . . . . . . . . . 56
CONDYLOX SOL . . . . . . . 18
conjugated estrogen/
bazedoxifene . . . . . . . 34
contraceptive foam . . . . . . 56
contraceptive gel . . . . . . . 56
COPAXONE . . . . . . . . . . 14
COPEGUS . . . . . . . . . . . 28
CORDARONE . . . . . . . . . .8
CORDRAN . . . . . . . . . . . 16
COREG . . . . . . . . . . . . . .9
CORGARD . . . . . . . . . . . .9
CORICIDIN TAB CGH/CLD . 43
CORTAID . . . . . . . . . . . . 56
CORTEF . . . . . . . . . . . . 21
cortisone acetate . . . . . . . 21
CORTISPORIN . . . . . . . . . 35
CORTISPORIN OTIC . . . . . 19
CORTIZONE . . . . . . . . . . 16
CORTIZONE-10 INTENSIVE
HEALING . . . . . . . . . . 16
COSOPT . . . . . . . . . . . . 35
COTELLIC . . . . . . . . . . . . 4
COZAAR . . . . . . . . . . . . .8
CPM/PSE . . . . . . . . . . . 43
CREON . . . . . . . . . . . . . 26
CRIXIVAN . . . . . . . . . . . . 29
crizotinib . . . . . . . . . . . . 4
CROLOM . . . . . . . . . . . . 34
cromolyn . . . . . . . . . . . . 47
cromolyn sodium . . . . . 20, 34
crotamiton . . . . . . . . . . . 18
CURITY ALCOHOL PADS . . 56
CUTIVATE . . . . . . . . . . . 16
cyanocobalamin . . . . . . . 49
CYCLESSA . . . . . . . . . . . 33
cyclobenzaprine . . . . . . . 32
CYCLOGYL . . . . . . . . . . . 36
cyclopentolate . . . . . . . . . 36
CYCLOPHOSPH . . . . . . . . .4
cyclophosphamide . . . . . . . 4
cycloserine . . . . . . . . . . 26
cyclosporine . . . . . . . . . . 6
cyclosporine, modified . . . . . 6
CYMBALTA . . . . . . . . . . . 38
cyproheptadine . . . . . . . . 19
CYPROHEPTADINE . . . . . . 19
CYSTAGON . . . . . . . . . . . 6
CYSTARAN . . . . . . . . . . . 36
cysteamine 0.44%
ophthalmic solution . . . . 36
cysteamine bitartrate . . . . . . 6
CYTOMEL . . . . . . . . . . . 23
CYTOTEC . . . . . . . . . . . 26
CYTOVENE . . . . . . . . . . . 28
CYTOXAN . . . . . . . . . . . . 4
D
dabrafenib . . . . . . . . . . . 4
DALLERGY DM . . . . . . . . 42
DALMANE . . . . . . . . . . . 39
danazol . . . . . . . . . . . . 33
DANOCRINE . . . . . . . . . . 33
DANTRIUM . . . . . . . . . . . 32
dantrolene . . . . . . . . . . . 32
dapsone . . . . . . . . . . . . 30
DAPSONE . . . . . . . . . . . 30
DARAPRIM . . . . . . . . . . . 30
darbepoetin alfa . . . . . . . . 7
darunavir . . . . . . . . . . . 29
darunavir/cobicistat . . . . . 30
dasatinib . . . . . . . . . . . . 4
DAYPRO . . . . . . . . . . 12, 31
DDAVP . . . . . . . . . . . . . 23
DEBROX . . . . . . . . . 19, 56
DECADRON . . . . . . . . . . 21
DE-CHLOR DM . . . . . . . . 45
decongestants . . . . . . . . 57
deferasirox . . . . . . . . . . . 7
ALL CAPS = Brand-name drug
Lower case = Generic drug
63
DELATESTRYL . . . . . . . . . 21
delavirdine . . . . . . . . . . . 29
DELFEN . . . . . . . . . . . . 56
DELSYM . . . . . . . . . . 44, 56
DELTASONE . . . . . . . . . . 21
DELZICOL . . . . . . . . . . . 25
DEMADEX . . . . . . . . . . . 10
DEMEROL . . . . . . . . . . . 13
DEPAKENE . . . . . . . . . . . 15
DEPAKOTE . . . . . . . . 14, 38
DEPAKOTE SPRINKLE . 14, 38
DEPEN TITRATABLE . . . . . 31
DEPO-ESTRADIOL . . . . . . 33
DEPO-PROVERA . . . . . . . 32
DEPO-TESTOSTERONE . . . 21
DERMAPHOR OINTMENT . . 55
DERMA-SMOOTHE OIL/FS . 16
dermatological baths . . . . . 56
DERMATOP . . . . . . . . . . 17
DESENEX . . . . . . . . . . . 17
desipramine . . . . . . . . . . 38
desmopressin . . . . . . . . . 23
desmopressin acetate inj . . . 23
desogestrel/EE . . . . . . 32, 33
desvenlafaxine fumarate
tab SR . . . . . . . . . . . 39
DESVENLAFAXINE FUMARATE
TAB SR . . . . . . . . . . . 39
desvenlafaxine succinate
tab SR . . . . . . . . . . . 39
desvenlafaxine tab SR . . . . 40
DESYREL . . . . . . . . . 39, 41
DETROL . . . . . . . . . . . . 48
dexamethasone . . . . . . . . 21
dexamethasone sodium
phosphate . . . . . . . . . 35
DEXASOL . . . . . . . . . . . 35
dexmethylphenidate . . . . . 37
dextroamphetamine . . . . . 37
dextromethorphan/brompheniramine/pseudoephedrine 44
dextromethorphan/carbinoxamine/pseudoephedrine 44
dextromethorphanguaifenesin . . . . . . . . 44
Index of Covered Drugs
dextromethorphanguaifenesin . . . . . . . . 44
dextromethorphan/
guaifenesin . . . . . . . . 44
dextromethorphan hbr . . . . 44
dextromethorphan polistirex
extended-release . . . . . 44
dextromethorphan/
promethazine . . . . . . . 44
dextromethorphan/quinidine 41
DEXTROSTAT . . . . . . . . . 37
D.H.E. 45 . . . . . . . . . . . . 13
DIABINESE . . . . . . . . . . . 22
DIAMOX SEQUELS . . . . . . 36
DIASTAT ACUDIAL . . . . . . . 14
diazepam . . . . . . . 14, 32, 37
diclofenac 1% gel . . . . . . . 31
diclofenac sodium . . . . . . 35
dicloxacillin . . . . . . . . . . 27
DICLOXACILLIN . . . . . . . . 27
dicyclomine . . . . . . . . . . 25
didanosine . . . . . . . . . . 29
didanosine delayed-release . 29
DIDRONEL . . . . . . . . . . . 23
DIFLUCAN . . . . . . . . 28, 34
diflunisal . . . . . . . . . . . . 31
digoxin . . . . . . . . . . . . . 8
DIHISTINE DH . . . . . . . . . 43
dihydroergotamine . . . . . . 13
DIHYDRO-PE SYP . . . . . . . 45
DILACOR XR . . . . . . . . . . 9
DILANTIN . . . . . . . . . . . . 15
DILANTIN INFATABS . . . . . 15
DILAUDID . . . . . . . . . . . . 13
diltiazem . . . . . . . . . . . . 9
diltiazem extended-release . . 9
diltiazem sustained-release . . 9
DIMEATAPP DRO
DECONGES . . . . . . . . 20
dimenhydrinate . . . . . . . . 57
DIMETAPP . . . . . . . . . . . 56
DIMETAPP CLD ELX/
ALLERGY . . . . . . . . . 42
DIMETAPP DRO DCON/CGH45
DIMETAPP DRO DECONGES 56
DIMETAPP ELX CLD/ALLE . . 42
DIMETAPP SYP CGH/CLD . . 43
dimethicone lotion 3% . . . . 55
dimethyl fumarate . . . . . . . 14
DIPENTUM . . . . . . . . . . . 25
diphenhydramine . . . . 19, 39
diphenhydraminephenylephrine soln . . . . 20
diphenoxylate/atropine . . . . 23
diphtheria-tetanus tox
adsorbed im . . . . . . . . 53
DIPROLENE . . . . . . . . . . 17
DIPROLENE AF . . . . . . . . 17
DIP/TET PED INJ . . . . . . . 53
dipyridamole . . . . . . . . . . 7
disopyramide . . . . . . . . . . 8
disopyramide extended-release8
disulfiram . . . . . . . . . . . 37
DITROPAN . . . . . . . . . . . 48
DITROPAN XL . . . . . . . . . 48
DIURIL . . . . . . . . . . . . . 10
DIURIL ORAL
SUSPENSION . . . . . . . 10
divalproex sodium
cap sprinkle . . . . . 14, 38
divalproex sodium
delayed-release . . . . 14, 38
docusate calcium plus . . . . 25
docusate potasssium . . . . . 25
docusate sodium . . . . . . . 25
dofetilide . . . . . . . . . . . . 8
DOK . . . . . . . . . . . . . . . 25
DOLOBID . . . . . . . . . . . . 31
DOLOPHINE . . . . . . . . . . 13
dolutegravir . . . . . . . . . . 30
DOMEBORO . . . . . . . . . . 56
DOMEBORO OTIC . . . . . . 19
donepezil . . . . . . . . . 11, 12
dornase alfa . . . . . . . . . . 52
dorzolamide . . . . . . . . . . 35
dorzolamide/timolol maleate 35
DOSTINEX . . . . . . . . . . . 23
DOVONEX . . . . . . . . . . . 17
doxazosin . . . . . . . . . . 8, 48
doxepin . . . . . . . . . . . . 38
ALL CAPS = Brand-name drug
Lower case = Generic drug
64
doxycycline hyclate . . . . . . 27
doxycycline monohydrate . . 27
DOXYCYCLINE
MONOHYDRATE . . . . . 27
DRAMAMINE . . . . . . . . . 57
DRISDOL . . . . . . . . . . . . 49
dronabinol . . . . . . . . . . . 24
DROXIA . . . . . . . . . . . . . .6
DUAVEE . . . . . . . . . . . . 34
DUETACT . . . . . . . . . . . . 22
DULCOLAX . . . . . . . . . . 57
DULERA . . . . . . . . . . . . 47
duloxetine . . . . . . . . . 38, 40
DUOFILM . . . . . . . . . 18, 58
DUONEB . . . . . . . . . . . . 47
DURADRYL . . . . . . . . . . 43
DURAGESIC . . . . . . . . . . 13
DURATUSS DM ELX . . . . . 44
DURICEF . . . . . . . . . . . . 26
DYAZIDE . . . . . . . . . . . . 10
E
ecothiophate . . . . . . . . . 36
ECOTRIN . . . . . . . .7, 31, 58
ED A-HIST TABLETS AND LIQUID . . . . . . . . . . . . . 43
EDGE OB CHW . . . . . . . . 51
edoxaban . . . . . . . . . . . . 6
EDURANT . . . . . . . . . . . 29
E.E.S. . . . . . . . . . . . . . . 27
efavirenz . . . . . . . . . . . . 29
efavirenz/emtricitabine/
tenofovir . . . . . . . . . . 29
EFFEXOR . . . . . . . . . . . . 38
EFFEXOR XR . . . . . . . . . . 38
EFUDEX . . . . . . . . . . . . 18
ELAVIL . . . . . . . . . . . 14, 38
elbasvir/grazoprevir . . . . . . 28
ELDEPRYL . . . . . . . . . . . 14
electrolyte . . . . . . . . . . . 49
electrolyte rehydrating soln . . 57
ELIDEL . . . . . . . . . . . . . 19
ELIMITE . . . . . . . . . . . . . 18
ELIQUIS . . . . . . . . . . . . . .6
ELOCON . . . . . . . . . . . . 17
Index of Covered Drugs
eltrombopag . . . . . . . . . . 53
elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide
fumarate . . . . . . . . . . 30
EMCYT . . . . . . . . . . . . . .4
EMEND . . . . . . . . . . . . . 24
EMETROL . . . . . . . . . . . 57
EMLA . . . . . . . . . . . . . . 18
emollients . . . . . . . . . . . 55
empagliflozin . . . . . . . . . 22
empagliflozin/metformin . . . 22
EMSAM . . . . . . . . . . . . . 40
emtricitabine . . . . . . . . . 29
emtricitabine/rilpivirine/
tenofovir . . . . . . . . . . 29
emtricitabine/tenofovir . . . . 29
EMTRIVA . . . . . . . . . . . . 29
enalapril . . . . . . . . . . . . . 7
enalapril/hydrochlorothiazide . 8
ENBREL . . . . . . . . . . . . 31
enfuvirtide . . . . . . . . . . . 28
ENGERIX-B . . . . . . . . . . . 53
ENJUVIA . . . . . . . . . . . . 34
enoxaparin . . . . . . . . . . . 7
entacapone . . . . . . . . . . 14
entecavir . . . . . . . . . . . . 28
ENTERIC COATEDNAPROSYN . . . . . . 12, 31
ENTOCORT EC . . . . . . . . 25
ENULOSE . . . . . . . . . . . 25
E-OINTMENT . . . . . . . . . 55
EPANED . . . . . . . . . . . . . 7
EPCLUSA . . . . . . . . . . . . 28
epinephrine . . . . . . . . . . 52
EPIPEN . . . . . . . . . . . . . 52
EPIPEN JR. . . . . . . . . . . . 52
EPIVIR . . . . . . . . . . . . . . 29
EPIVIR HBV . . . . . . . . . . . 28
epoetin alfa . . . . . . . . . . . 7
EPOGEN . . . . . . . . . . . . .7
EPZICOM . . . . . . . . . . . . 29
EQL B COMPLEX . . . . . . . 49
EQUETRO . . . . . . . . . . . 39
ergocalciferol . . . . . . . . . 49
ergotamine/caffeine . . . . . 13
ergotamine tartrate/caffeine . 13
ERIVEDGE . . . . . . . . . . . .6
erlotinib . . . . . . . . . . . . . 4
ERYC . . . . . . . . . . . . . . 27
ERYGEL . . . . . . . . . . . . 16
ERY-TAB . . . . . . . . . . . . 27
ERYTHROCIN . . . . . . . . . 27
erythromycin . . . . . . . 16, 36
ERYTHROMYCIN . . . . . . . 36
erythromycin/benzoyl peroxide16
erythromycin delayed-release 27
erythromycin ethylsuccinate . 27
erythromycin stearate . . . . . 27
erythromycin/sulfisoxazole . . 27
ESBRIET . . . . . . . . . . . . 53
escitalopram . . . . . . . . . 38
escitalopram & methylfolate-B12-B6-D cap thpk . 40
escitalopram oxalate soln . . 40
ESKALITH CR . . . . . . . . . 38
esomeprazole . . . . . . . . . 24
estazolam . . . . . . . . . . . 39
ESTRACE . . . . . . . . . . . . 33
estradiol . . . . . . . . . . 33, 34
estradiol cypionate . . . . . . 33
estradiol td . . . . . . . . . . . 34
estramustine
phosphate sodium . . . . . 4
estrogens, conjugated . . . . 33
estrogens, conjugated/
medroxyprogesterone . . 34
estrogens, conjugated,
synthetic A . . . . . . . . . 34
estrogens, conjugated,
synthetic B . . . . . . . . 34
estropipate . . . . . . . . . . 34
etanercept . . . . . . . . . . . 31
ethambutol . . . . . . . . . . 26
ethionamide . . . . . . . . . . 26
ethosuximide . . . . . . . . . 15
ethynodiol diacetate/EE . . . 33
etidronate . . . . . . . . . . . 23
etodolac . . . . . . . . . . 12, 31
etonogestrel/EE . . . . . . . . 32
etoposide . . . . . . . . . . . . 6
ALL CAPS = Brand-name drug
Lower case = Generic drug
65
etravirine . . . . . . . . . . . . 30
EULEXIN . . . . . . . . . . . . .5
EURAX . . . . . . . . . . . . . 18
everolimus . . . . . . . . . . 4, 6
EVISTA . . . . . . . . . . . . . 23
EXCEDRIN MIGRAINE . . . . 12
EXELON . . . . . . . . . . . . 12
exemestane . . . . . . . . . . . 5
EXJADE . . . . . . . . . . . . . .7
ezetimibe . . . . . . . . . . . 11
ezogabine . . . . . . . . . . . 15
F
FABB . . . . . . . . . . . . . . 49
famotidine . . . . . . . . 24, 57
FANAPT . . . . . . . . . . . . . 40
FARESTON . . . . . . . . . . . .5
FARYDAK . . . . . . . . . . . . .4
FAZACLO . . . . . . . . . . . . 39
febuxostat . . . . . . . . . . . 32
felbamate . . . . . . . . . . . 15
FELBATOL . . . . . . . . . . . 15
FELDENE . . . . . . . . . 12, 32
felodipine extended-release . . 9
FEMARA . . . . . . . . . . . . .5
fenofibrate . . . . . . . . . . . 10
fentanyl transdermal . . . . . 13
FEOSOL . . . . . . . . . . 49, 58
FERGON . . . . . . . . . . . . 58
ferrous bisglycinate/
polysaccarides iron . . . . 49
ferrous sulfate . . . . . . . . . 49
FETZIMA . . . . . . . . . . . . 40
filgrastim . . . . . . . . . . . . 7
FINACEA . . . . . . . . . . . . 16
finasteride . . . . . . . . . . . 48
fingolimod . . . . . . . . . . . 14
FIORICET . . . . . . . . . . . . 12
FIORICET W/CODEINE . . . . 12
FIORINAL . . . . . . . . . . . . 12
FIORINAL W/CODEINE . . . . 12
FIRAZYR . . . . . . . . . . . . 53
FISH OIL . . . . . . . . . . . . 10
fish oil caps . . . . . . . . . . 10
FLAGYL . . . . . . . . . . 30, 34
Index of Covered Drugs
FLAVOXATE . . . . . . . . . . 48
flavoxate hcl . . . . . . . . . . 48
flecainide . . . . . . . . . . . . 8
FLEET ENEMA . . . . . . . . . 57
FLEET PHOSPHO-SODA . . . 57
FLEXERIL . . . . . . . . . . . . 32
FLOMAX . . . . . . . . . . . . 48
FLONASE . . . . . . . . . . . . 20
FLORANEX . . . . . . . . . . . 26
FLORINEF . . . . . . . . . . . 21
FLOXIN . . . . . . . . . . . . . 27
FLOXIN OTIC . . . . . . . . . . 19
FLUARIX QUAD . . . . . . . . 54
FLUBLOK . . . . . . . . . . . . 53
FLUCELVAX . . . . . . . . . . 54
fluconazole . . . . . . . . 28, 34
fludrocortisone . . . . . . . . 21
FLULAVAL QUAD . . . . . . . 54
FLUMADINE . . . . . . . . . . 28
fluocinolone acetonide . . . . 16
fluocinonide . . . . . . . . . . 17
fluocinonide emulsified base 17
fluoride . . . . . . . . . . . . . 49
fluoride dental rinse . . . . . 58
fluorometholone . . . . . . . 35
FLUOROPLEX . . . . . . . . . 18
fluorouracil . . . . . . . . . . 18
fluoxetine . . . . . . . . . . . 38
FLUOXETINE . . . . . . . . . . 40
fluoxetine capsule . . . . . . . 40
fluoxetine HCL cap
delayed release . . . . . . 40
fluoxetine tablet . . . . . . . . 40
fluphenazine . . . . . . . . . 41
fluphenazine decanoate . . . 41
flurandrenolide . . . . . . . . 16
flurazepam . . . . . . . . . . 39
flurbiprofen . . . . . . . . . . 35
flutamide . . . . . . . . . . . . 5
fluticasone . . . . . . . . . . . 20
fluticasone furoate . . . . . . 47
fluticasone propionate . . . . 16
fluticasone/vilanterol . . . . . 47
FLUVIRIN . . . . . . . . . . . . 54
fluvoxamine . . . . . . . . . . 37
fluvoxamine maleate cap SR 40
FLUZONE HD PF . . . . . . . 54
FLUZONE QUAD . . . . . . . 54
FLUZONE SPLT . . . . . . . . 53
FML . . . . . . . . . . . . . . 35
FML FORTE . . . . . . . . . . 35
FML LIQUIFILM . . . . . . . . 35
FOCALIN . . . . . . . . . . . . 37
folic acid . . . . . . . . . . . . 49
FOLIC ACID . . . . . . . . . . 49
folic acid-vitamin
b6-vitamin b12 . . . . . . 49
FOLTABS PAK PLUS DHA RE
OB + DHA PAK . . . . . . 50
FOLTABS PRENATAL . . . . . 51
FORFIVO XL . . . . . . . . . . 39
FORTEO . . . . . . . . . . . . 23
FORTICAL . . . . . . . . . . . 23
FOSAMAX . . . . . . . . . . . 23
fosamprenavir . . . . . . . . . 29
fosinopril . . . . . . . . . . . . 7
fosinopril/hydrochlorothiazide 8
FURADANTIN SUSP . . . . . 30
furosemide . . . . . . . . . . 10
FUZEON KIT . . . . . . . . . . 28
G
gabapentin . . . . . . . . . . 15
GABITRIL . . . . . . . . . . . . 15
galantamine . . . . . . . . . . 12
ganciclovir . . . . . . . . . . . 28
GARDASIL . . . . . . . . . . . 53
GARDASIL 9 . . . . . . . . . . 53
gatifloxin . . . . . . . . . . . . 36
GATTEX . . . . . . . . . . . . 26
gefitinib . . . . . . . . . . . . . 4
GEL-KAM . . . . . . . . . . . . 49
gemfibrozil . . . . . . . . . . . 10
GENGRAF . . . . . . . . . . . .6
GENTAK . . . . . . . . . . 16, 36
gentamicin . . . . . . . . 16, 36
gentamicin/prednisolone
acetate . . . . . . . . . . . 35
GENTEX ADE . . . . . . . . . 51
GENVOYA . . . . . . . . . . . 30
ALL CAPS = Brand-name drug
Lower case = Generic drug
66
GEODON . . . . . . . . . . . . 41
GERAVIM . . . . . . . . . . . . 49
GG/CODEINE . . . . . . . . . 43
GG/DM CR . . . . . . . . . . . 44
GG/PSE CR . . . . . . . . . . 45
GILENYA . . . . . . . . . . . . 14
GILOTRIF . . . . . . . . . . . . .4
glatiramer acetate . . . . . . . 14
GLEEVEC . . . . . . . . . . . . 4
GLEOSTINE . . . . . . . . . . . 4
glimepiride . . . . . . . . . . 22
glipizide . . . . . . . . . . . . 22
glipizide extended-release . . 22
glipizide-metformin . . . . . . 22
GLUCAGON . . . . . . . . . . 21
glucagon, human
recombinant . . . . . . . . 21
GLUCOPHAGE . . . . . . . . 22
GLUCOPHAGE ER . . . . . . 22
glucose gel 40% . . . . . . . 56
glucose oral tablets . . . . . . 56
GLUCOTROL . . . . . . . . . 22
GLUCOTROL XL . . . . . . . . 22
GLUCOVANCE . . . . . . . . 22
GLUTOSE 15 . . . . . . . . . 56
glyburide . . . . . . . . . . . . 22
glyburide, micronized . . . . . 22
glycerin . . . . . . . . . . . . 25
GLYCERIN SUPPOSITORY . . 25
GLYCERIN TOPICAL . . . . . 55
glycerol phenylbutyrate . . . . 53
glycopyrrolate . . . . . . . . . 25
GLYNASE . . . . . . . . . . . . 22
GRIFULVIN V . . . . . . . . . . 28
griseofulvin microsize . . . . . 28
griseofulvin ultramicrosize . . 28
GRIS-PEG . . . . . . . . . . . 28
GUAIFED . . . . . . . . . . . . 44
guaifenesin . . . . . . . . . . 44
guaifenesin extended-release 44
guaifenesin/
pseudoephedrine . . . . . 44
guaifenesin/
pseudoephedrine/
dextromethorphan . . . . 44
Index of Covered Drugs
guaifenesin/pseudoephedrine
extended-release . . . 44, 45
GUAIFEN PSE . . . . . . . . . 45
guanabenz . . . . . . . . . . 11
guanfacine . . . . . . . . . . . 8
guanfacine ER . . . . . . . . 37
GUIATUSS AC . . . . . . . . . 43
GUIATUSS DAC . . . . . . . . 44
GYNE-LOTRIMIN . . . . . 34, 55
GYNOL II . . . . . . . . . . . . 56
HUMULIN . . . . . . . . . . . 56
HUMULIN 70/30 . . . . . . . 22
HUMULIN N . . . . . . . . . . 21
HUMULIN R . . . . . . . . . . 22
HYCAMTIN . . . . . . . . . . . .6
HYCODAN . . . . . . . . . . . 45
hydralazine . . . . . . . . . . 11
HYDREA . . . . . . . . . . . . . 6
hydrochlorothiazide . . . . . . 10
HYDROCHLOROTHIAZIDE . 10
HYDROCODO/GG SYP . . . 45
H
hydrocodone/acetaminophen13
HALCION . . . . . . . . . . . . 39 hydrocodone/chlorpheniramine/
HALDOL . . . . . . . . . . . . 42
phenylephrine . . . . . . . 45
HALDOL DECANOATE . . . . 42 hydrocodone ER . . . . . . . 13
halobetasol . . . . . . . . . . 17 hydrocodone/guaifenesin . . 45
haloperidol . . . . . . . . . . 42 hydrocodone/
haloperidol decanoate . . . . 42
homatropine . . . . . . . 45
HAVRIX . . . . . . . . . . . . . 53 HYDROCODONE/
HECORIA . . . . . . . . . . . . 6
TAB HOMATROP . . . . . 45
heparin . . . . . . . . . . . . . 7 hydrocortisone . .16, 18, 21, 25
HEPARIN . . . . . . . . . . . . .7 hydrocortisone/aloe . . . . . 16
hepatitis a vaccine susp . . . 53 hydrocortisone butyrate . . . 16
hepatitis b vaccine . . . . . . 53 hydrocortisone crm, oint . . . 56
HEPSERA . . . . . . . . . . . 28 hydrocortisone valerate . . . 17
HETLIOZ . . . . . . . . . . . . 40 HYDROMET SYP . . . . . . . 45
hexachlorophene . . . . . . . 18 hydromorphone . . . . . . . . 13
HEXALEN . . . . . . . . . . . . 4 hydroxychloroquine . . . 30, 31
HIPREX . . . . . . . . . . . . . 48 hydroxyurea . . . . . . . . . . 6
HISTACOL DM . . . . . . . . . 42 hydroxyzine HCL . . . . . . . 19
HISTEX . . . . . . . . . . . . . 43 hydroxyzine pamoate . . . . . 19
HISTUSSIN HC . . . . . . . . 45 hyoscyamine, methenamine,
homatropine . . . . . . . . . . 36
phenyl salicylate, sodium
HUMALOG . . . . . . . . . . . 22
phosphate monobasic,
HUMALOG MIX 50/50 . . . . 22
methylene blue . . . . . . 48
HUMALOG MIX 75/25 . . . . 22 hyoscyamine sulfate . . . . . 25
human papillomavirus (hpv) 9-va- hyoscyamine sulfate
lent recomb vac . . . . . . 53
extended-release . . . . . 25
human papillomavirus (hpv) bival HYPERCARE 20% . . . . . . . 18
(type 16, 18) recmb vac . 53 HYPERTET S/D . . . . . . . . 54
human papillomavirus (hpv)
HYPOTEARS . . . . . . . . . . 57
quadrivalent recombinant
HYTONE . . . . . . . . . . . . 16
vac . . . . . . . . . . . . . 53 HYTRIN . . . . . . . . . . . 8, 48
HUMATIN . . . . . . . . . . . . 30 HYZAAR . . . . . . . . . . . . . 8
HUMIRA . . . . . . . . . . . . 31
ALL CAPS = Brand-name drug
Lower case = Generic drug
67
I
IBRANCE . . . . . . . . . . . . .5
ibrutinib . . . . . . . . . . . . . 4
IBUOROFEN TAB COLD/SIN 46
ibuprofen . . . . . . . 12, 31, 58
icatibant . . . . . . . . . . . . 53
ICLUSIG . . . . . . . . . . . . . 5
idelalisib . . . . . . . . . . . . . 4
ILARIS . . . . . . . . . . . . . . 52
iloperidone . . . . . . . . . . 40
imatinib mesylate . . . . . . . . 4
IMBRUVICA . . . . . . . . . . . 4
IMDUR . . . . . . . . . . . . . 11
imipramine HCL . . . . . . . 38
imipramine pamoate . . . . . 40
imiquimod 5% cream . . . . . 18
IMITREX . . . . . . . . . . . . 13
IMODIUM A-D . . . . . . . 23, 57
IMURAN . . . . . . . . . . . 6, 31
INCRELEX . . . . . . . . . . . 23
INCRUSE ELLIPTA . . . . . . 47
indacaterol . . . . . . . . . . . 47
indapamide . . . . . . . . . . 10
INDERAL . . . . . . . . . . 9, 14
INDERAL LA . . . . . . . . . . .9
INDERIDE . . . . . . . . . . . . 9
indinavir . . . . . . . . . . . . 29
INDOCIN . . . . . . . . . 12, 31
indomethacin . . . . . . . 12, 31
INFLAMASE FORTE . . . . . . 35
influenza virus vaccine recombinant hemagglutinin (ha) . 53
influenza virus vaccine split . 53
influenza virus vaccine split
high-dose pf . . . . . . . . 54
influenza virus vaccine split pf54
influenza virus vaccine split
quadrivalent . . . . . . . . 54
influenza virus vaccine tiss-cult
subunit . . . . . . . . . . . 54
influenza virus vaccine types
a&b surface antigen . . . 54
INLYTA . . . . . . . . . . . . . . 4
inositol niacinate . . . . . . . 10
insulin aspart . . . . . . . . . 21
Index of Covered Drugs
insulin aspart protamine 70%/
insulin aspart 30% . . . . 21
insulin glargine . . . . . . . . 21
insulin human . . . . . . . . . 21
insulin isophane . . . . . . . . 21
insulin isophane human . . . 21
insulin isophane human 70%/
regular 30% . . . . . . . . 22
insulin isophane/regular . . . 22
insulin lisopro pro/lispro . . . 22
insulin lisopro prot/lispro . . . 22
insulin lispro . . . . . . . . . . 22
insulin regular . . . . . . . . . 22
insulin . . . . . . . . . . . . . 56
INTAL . . . . . . . . . . . . . . 47
INTELENCE . . . . . . . . . . 30
interferon alfa-2b . . . . . . 5, 28
interferon beta-1a . . . . . . . 14
INTRON A . . . . . . . . . . 5, 28
INTUNIV . . . . . . . . . . . . 37
INVEGA . . . . . . . . . . . . . 40
INVEGA SUSTENNA . . . . . 41
INVEGA TRINZA . . . . . . . . 41
INVIRASE . . . . . . . . . . . . 29
INVOKAMET . . . . . . . . . . 22
INVOKANA . . . . . . . . . . . 22
ipratropium . . . . . . . . . . 47
ipratropium/albuterol . . . . . 47
ipratropium HFA . . . . . . . 47
ipratropium nasal . . . . . . . 20
IRENKA . . . . . . . . . . . . . 40
IRESSA . . . . . . . . . . . . . .4
iron . . . . . . . . . . . . . . . 58
iron polysaccharides . . . . . 58
ISENTRESS . . . . . . . . . . 30
ISENTRESS CHEWABLE . . . 30
ISENTRESS SUSP . . . . . . . 31
ISMO . . . . . . . . . . . . . . 11
isocarboxazid . . . . . . . . . 40
isoniazid . . . . . . . . . . . . 26
ISONIAZID . . . . . . . . . . . 26
ISOPTO ATROPINE . . . . . . 36
ISOPTO CARPINE . . . . . . . 36
ISOPTO HOMATROPINE . . . 36
ISOPTO HYOSCINE . . . . . . 36
ISORDIL . . . . . . . . . . . . 11
ISORDIL S.L. . . . . . . . . . . 11
isosorbide dinitrate . . . . . . 11
ISOSORBIDE DINITRATE ER . 11
isosorbide dinitrate
extended-release . . . . . 11
isosorbide mononitrate . . . . 11
isosorbide mononitrate
extended-release . . . . . 11
isotretinoin . . . . . . . . . . . 15
itraconazole . . . . . . . . . . 28
ivacaftor . . . . . . . . . . . . 52
ivermectin . . . . . . . . . . . 26
ixazomib . . . . . . . . . . . . 5
J
JADENU . . . . . . . . . . . . . 7
JAKAFI . . . . . . . . . . . . . . 5
JARDIANCE . . . . . . . . . . 22
JENTADUETO . . . . . . . . . 22
K
KALETRA . . . . . . . . . . . . 29
KALEXATE . . . . . . . . . . . 11
KALYDECO . . . . . . . . . . . 52
KALYDECO GRANULES . . . 52
KAOPECTATE . . . . . . . . . 57
KAYEXALATE . . . . . . . . . 11
K-DUR 10 . . . . . . . . . . . . 52
K-DUR 20 . . . . . . . . . . . . 52
KEFLEX . . . . . . . . . . . . . 27
KENALOG . . . . . . . . . . . 17
KENALOG IN ORABASE . . . 21
KEPPRA . . . . . . . . . . . . 15
ketoconazole . . . . . 17, 18, 28
ketoprofen . . . . . . . . 12, 31
ketorolac . . . . . . . . . . . . 35
ketorolac tromethamine . . . 12
ketotifen . . . . . . . . . . . . 34
KHEDEZLA . . . . . . . . . . . 40
KINERET . . . . . . . . . . . . 31
KLARON . . . . . . . . . . . . 16
KLONOPIN . . . . . . . . 14, 37
K-LOR . . . . . . . . . . . . . . 52
KLOR-CON 8 . . . . . . . . . 52
ALL CAPS = Brand-name drug
Lower case = Generic drug
68
KLOR-CON 10 . . . . . . . . . 52
K-LYTE . . . . . . . . . . . . . 52
KOMBIGLYZE . . . . . . . . . 22
KONSYL-D . . . . . . . . . . . 57
KORLYM . . . . . . . . . . . . 23
K-PHOS NEUTRAL . . . . . . 52
K-PHOS ORIGINAL . . . . . . 52
KUVAN . . . . . . . . . . . . . 23
L
labetalol . . . . . . . . . . . . . 9
LAC-HYDRIN . . . . . . . . . . 18
lacosamide . . . . . . . . . . 15
LACTINOL . . . . . . . . . . . 18
lactobacillus . . . . . . . . . . 26
lactulose . . . . . . . . . . . . 25
LAMICTAL . . . . . . . . . . . 15
LAMICTAL CD CHEW TAB . . 15
LAMICTAL STARTER KIT . . . 15
LAMISIL . . . . . . . . . . . . . 28
LAMISIL AT . . . . . . . . . . . 17
LAMISIL AT SPRAY . . . . . . 28
lamivudine . . . . . . . . 28, 29
lamivudine/zidovudine . . . . 29
lamotrigine . . . . . . . . . . 15
lamotrigine chew
dispersable tab . . . . . . 15
lamotrigine starter kit . . . . . 15
LANOXIN . . . . . . . . . . . . .8
lansoprazole . . . . . . . . . . 24
lansoprazole delayed-release 24
LANTUS . . . . . . . . . . . . 21
lapatinib ditosylate . . . . . . . 4
LARIAM . . . . . . . . . . . . . 30
LASIX . . . . . . . . . . . . . . 10
latanoprost . . . . . . . . . . 36
LATUDA . . . . . . . . . . . . 40
laxative enemas . . . . . . . . 57
laxatives . . . . . . . . . . . . 57
leflunomide . . . . . . . . . . 31
lenalidomide . . . . . . . . . . 5
lenvatinib . . . . . . . . . . . . 4
LENVIMA . . . . . . . . . . . . .4
LETAIRIS . . . . . . . . . . . . 11
letrozole . . . . . . . . . . . . . 5
Index of Covered Drugs
leucovorin calcium . . . . . . . 6
LEUKERAN . . . . . . . . . . . .4
LEUKINE . . . . . . . . . . . . .7
leuprolide . . . . . . . . . . . . 5
levalbuterol HCl . . . . . . . . 47
LEVAQUIN . . . . . . . . . . . 27
levetiracetam . . . . . . . . . 15
levobunolol . . . . . . . . . . 35
levocetirizine . . . . . . . . . 20
levofloxacin . . . . . . . . . . 27
levomilnacipran . . . . . . . . 40
levonorgestrel . . . . . . . . . 32
levonorgestrel/EE . . . . 32, 33
levothyroxine . . . . . . . . . 23
LEVOXYL . . . . . . . . . . . . 23
LEVSIN . . . . . . . . . . . . . 25
LEVSINEX . . . . . . . . . . . 25
LEXAPRO . . . . . . . . . 38, 40
LEXIVA . . . . . . . . . . . . . 29
LIALDA . . . . . . . . . . . . . 25
LIBRIUM . . . . . . . . . . . . 37
LIDAMANTEL . . . . . . . . . 18
LIDEX . . . . . . . . . . . . . . 17
LIDEX E . . . . . . . . . . . . . 17
lidocaine . . . . . . . . . . . . 18
lidocaine/prilocaine . . . . . 18
lidocaine viscous . . . . . . . 21
LIMBITROL . . . . . . . . . . . 38
linagliptin . . . . . . . . . . . 22
linagliptin/metformin . . . . . 22
linezolid . . . . . . . . . . . . 30
liothyronine . . . . . . . . . . 23
liotrix . . . . . . . . . . . . . . 23
LIPITOR . . . . . . . . . . . . . 10
LIPOFEN . . . . . . . . . . . . 10
liraglutide . . . . . . . . . . . 23
lisdexamfetamine . . . . . . . 37
lisinopril . . . . . . . . . . . . . 7
lisinopril/hydrochlorothiazide . 8
lithium carbonate . . . . . . . 38
LITHIUM CARBONATE . . . . 38
lithium carbonate extendedrelease . . . . . . . . . . . 38
LITHOBID . . . . . . . . . . . . 38
LMX-4 . . . . . . . . . . . . . . 18
LOCOID . . . . . . . . . . . . . 16
LODINE . . . . . . . . . . 12, 31
LOESTRIN 1.5/30 . . . . . . . 33
LOESTRIN 1/20 . . . . . . . . 32
LOESTRIN FE 1.5/30 . . . . . 33
LOESTRIN FE 1/20 . . . . . . 33
LOFIBRA . . . . . . . . . . . . 10
LOMOTIL . . . . . . . . . . . . 23
lomustine . . . . . . . . . . . . 4
LONITEN . . . . . . . . . . . . 11
LONSURF . . . . . . . . . . . . 4
LO/OVRAL . . . . . . . . . . . 33
loperamide . . . . . . . . . . 23
LOPERAMIDE . . . . . . . . . 23
LOPID . . . . . . . . . . . . . . 10
lopinavir/ritonavir . . . . . . . 29
LOPRESSOR . . . . . . . . . . .9
loratadine . . . . . . . . . . . 20
loratadine/pseudoephedrine 56
loratadine/pseudoephedrine
extended-release . . . . . 20
loratadine &
pseudoephedrine SR . . 45
lorazepam . . . . . . . . . . . 37
LORCET . . . . . . . . . . . . 13
LORTAB . . . . . . . . . . . . 13
LORTAB ELIXIR . . . . . . . . 13
losartan . . . . . . . . . . . . . 8
losartan/HCTZ . . . . . . . . . 8
LOTENSIN . . . . . . . . . . . . 7
LOTENSIN HCT . . . . . . . . . 8
LOTREL . . . . . . . . . . . . . 10
LOTRIMIN AF . . . . . . . 17, 55
LOTRISONE . . . . . . . . . . 17
lovastatin . . . . . . . . . . . . 10
LOVENOX . . . . . . . . . . . . 7
loxapine . . . . . . . . . . . . 42
loxapine aerosol powder
breath activated . . . . . 40
LOXITANE . . . . . . . . . . . 42
LOZOL . . . . . . . . . . . . . 10
LUDIOMIL . . . . . . . . . . . 39
lumacaftor/ivacaftor . . . . . 52
LUPRON . . . . . . . . . . . . .5
LUPRON DEPOT . . . . . . . . 5
ALL CAPS = Brand-name drug
Lower case = Generic drug
69
LUPRON DEPOT 6-MONTH . .5
LUPRON DEPOT-PED . . . . . .5
lurasidone . . . . . . . . . . . 40
LURIDE . . . . . . . . . . . . . 49
LURIDE LOZI-TABS . . . . . . 49
LUVOX . . . . . . . . . . . . . 37
LUVOX CR . . . . . . . . . . . 40
LYNPARZA . . . . . . . . . . . .6
LYRICA . . . . . . . . . . . . . 15
LYSODREN . . . . . . . . . . . .6
LYSTEDA . . . . . . . . . . . . 34
M
MAALOX . . . . . . . . . 24, 57
macitentan . . . . . . . . . . 11
MACROBID . . . . . . . . . . 30
MACRODANTIN . . . . . . . . 30
MAG64 . . . . . . . . . . . . . 49
magnesium chloride . . . . . 49
magnesium hydroxide susp . 57
magnesium oxide . . . . 50, 58
MAG-OX . . . . . . . . . . 50, 58
malathion . . . . . . . . . . . 18
MAPAP COLD TAB . . . . . . 46
maprotiline . . . . . . . . . . 39
maraviroc . . . . . . . . . . . 30
MARINOL . . . . . . . . . . . . 24
MARPLAN . . . . . . . . . . . 40
MATERNA . . . . . . . . . . . 51
MATULANE . . . . . . . . . . . 6
MAVIK . . . . . . . . . . . . . . .8
MAXALT/MAXALT MLT . . . . 13
MAXITROL . . . . . . . . . . . 35
MAXZIDE . . . . . . . . . . . . 10
M-CLEAR WC . . . . . . . . . 43
measles, mumps & rubella virus
vaccines for inj . . . . . . 54
mecasermin . . . . . . . . . . 23
meclizine . . . . . . . . . 24, 57
MEDROL . . . . . . . . . . . . 21
medroxyprogesterone
acetate . . . . . . . . 32, 34
mefloquine . . . . . . . . . . 30
MEGACE . . . . . . . . . . . . .5
megestrol acetate . . . . . . . 5
Index of Covered Drugs
MEKINIST . . . . . . . . . . . . 5
MELLARIL . . . . . . . . . . . 42
meloxicam . . . . . . . . 12, 31
melphalan . . . . . . . . . . . 4
memantine . . . . . . . . . . 12
MENACTRA . . . . . . . . . . 54
meningococcal (a, c, y, and
w-135) . . . . . . . . . . . 54
meningococcal (a, c, y, and
w-135) conjugate vaccine 54
meningococcal (a, c, y, and
w-135) oligo conj vac
for inj . . . . . . . . . . . . 54
MENOMUNE . . . . . . . . . . 54
MENVEO . . . . . . . . . . . . 54
meperidine . . . . . . . . . . 13
MEPHYTON . . . . . . . . . . 50
MEPRON . . . . . . . . . . . . 30
mercaptopurine . . . . . . . . 4
mesalamine . . . . . . . . . . 25
mesalamine extended-release25
mesna tab . . . . . . . . . . . 6
MESNEX . . . . . . . . . . . . .6
MESTINON . . . . . . . . . . . 14
MESTINON TIMESPAN . . . . 14
METADATE ER . . . . . . . . . 38
METAGLIP . . . . . . . . . . . 22
METAMUCIL . . . . . . . . . . 57
metaproterenol . . . . . . . . 47
METAPROTERENOL SYRUP 47
metformin . . . . . . . . . . . 22
metformin ER . . . . . . . . . 22
metformin/glyburide . . . . . 22
methadone . . . . . . . . . . 13
methazolamide . . . . . . . . 36
methenamine hippurate . . . 48
METHERGINE . . . . . . . . . 23
METHERGINE . . . . . . . . . 34
methimazole . . . . . . . . . . 23
methocarbamol . . . . . . . . 32
methotrexate . . . . . . . . . 31
methsuximide . . . . . . . . . 15
methyldopa . . . . . . . . . . 11
methyldopa/HCTZ . . . . . . 11
methylergonovine . . . . 23, 34
methylphenidate . . . . . . . 37
methylphenidate
extended-release . . . 37, 38
methylprednisolone . . . . . . 21
metipranolol . . . . . . . . . . 35
metoclopramide . . . . . . . 24
metolazone . . . . . . . . . . 10
metoprolol . . . . . . . . . . . 9
metoprolol succinate . . . . . . 9
metreleptin . . . . . . . . . . 40
METROCREAM . . . . . . . . 18
METROGEL . . . . . . . . . . 18
METROGEL 1% . . . . . . . . 34
METROGEL-VAGINAL . . . . 34
METROLOTION . . . . . . . . 18
metronidazole . . . . 18, 30, 34
MEVACOR . . . . . . . . . . . 10
mexiletine . . . . . . . . . . . . 8
MEXITIL . . . . . . . . . . . . . .8
MIACALCIN . . . . . . . . . . 23
MICATIN . . . . . . . . . . 17, 55
miconazole . . . . . . 17, 34, 55
MICRO-K 10 . . . . . . . . . . 52
MICRONASE . . . . . . . . . . 22
MICROZIDE . . . . . . . . . . 10
MIDAMOR . . . . . . . . . . . 10
midodrine . . . . . . . . . . . 11
mifepristone . . . . . . . . . . 23
MIGERGOT SUPPOSITORIES13
MIGRANAL . . . . . . . . . . . 13
MILK OF MAGNESIA . . . . . 57
MINIPRESS . . . . . . . . . . . .8
MINOCIN . . . . . . . . . . . . 27
minocycline . . . . . . . . . . 27
minoxidil . . . . . . . . . . . . 11
MINUTUSS DR SYP . . . . . . 45
MIRALAX . . . . . . . . . . . . 25
MIRAPEX . . . . . . . . . . . . 14
MIRCETTE . . . . . . . . . . . 32
mirtazapine . . . . . . . . . . 39
mirtazapine ODT . . . . . . . 40
MIRVASO . . . . . . . . . . . . 18
misoprostol . . . . . . . . . . 26
MITIGARE . . . . . . . . . . . 32
mitotane . . . . . . . . . . . . . 6
ALL CAPS = Brand-name drug
Lower case = Generic drug
70
M-M-R II . . . . . . . . . . . . . 54
MOBIC . . . . . . . . . . 12, 31
MODICON . . . . . . . . . . . 33
MODURETIC . . . . . . . . . . 10
moexipril hcl . . . . . . . . . . 7
moexipril-hydrochlorothiazide . 8
mometasone . . . . . . . . . 47
mometasone/formoterol . . . 47
mometasone furoate . . . . . 17
mometasone inhalation . . . 47
MONISTAT . . . . . . . . 34, 55
MONISTAT 3 . . . . . . . . . . 34
MONISTAT-DERM . . . . . . . 17
MONOPRIL . . . . . . . . . . . 7
MONOPRIL-HCT . . . . . . . . .8
montelukast . . . . . . . . . . 48
morphine . . . . . . . . . . . 13
morphine extended-release . 13
MOTRIN . . . . . . . . . . 12, 31
MOTRIN IB . . . . . . . . . . . 58
MOVANTIK . . . . . . . . . . . 26
MOZOBIL . . . . . . . . . . . . .7
MS CONTIN . . . . . . . . . . 13
MSIR . . . . . . . . . . . . . . 13
MUCINEX . . . . . . . . . . . 44
MUCINEX D . . . . . . . . . . 45
MUCINEX DM . . . . . . . . . 44
MUCOMYST . . . . . . . . . . 52
multiple vitamin . . . . . . . . 50
MULTI SYMPTOM TAB
COLD RLF . . . . . . . . . 46
multivitamins/fluoride/±iron . 50
multivitamins/minerals . . . . 50
mupirocin . . . . . . . . . . . 16
MURINE . . . . . . . . . . . . 57
MURO 128 . . . . . . . . . . . 37
MYALEPT . . . . . . . . . . . . 40
MYAMBUTOL . . . . . . . . . 26
MYCELEX . . . . . . . . . 17, 28
MYCITRACIN . . . . . . . . . . 56
MYCOBUTIN . . . . . . . . . . 26
mycophenolate mofetil . . . . .6
mycophenolate sodium . . . . 6
MYCOSTATIN . . . . . . . 17, 28
MYFORTIC . . . . . . . . . . . .6
Index of Covered Drugs
MYLANTA . . . . . . . . . 24, 57
MYLERAN . . . . . . . . . . . . 4
MYLICON . . . . . . . . . . . 57
MYSOLINE . . . . . . . . . . . 15
N
nabumetone . . . . . . . . . . 31
nadolol . . . . . . . . . . . . . 9
naloxegol . . . . . . . . . . . 26
naloxone . . . . . . . . . . . . 41
NALOXONE INJ . . . . . . . . 41
naltrexone . . . . . . . . . 37, 41
NAMENDA . . . . . . . . . . . 12
naphazoline/antazoline . . . 34
naphazoline/glycerin . . . . . 35
naphazoline HCL . . . . . . . 35
naphazoline/zinc sulfate . . . 35
NAPHCON A . . . . . . . . . . 57
NAPROSYN . . . . . . . . 12, 31
naproxen . . . . . . . . . 12, 31
naproxen delayed release 12, 31
naratriptan . . . . . . . . . . . 13
NARCAN NASAL SPRAY . . . 41
NARDIL . . . . . . . . . . . . . 40
NASACORT ALLERGY . . . . 20
NASALCROM . . . . . . . . . 20
nasal sprays . . . . . . . . . . 56
NATALCARE . . . . . . . . . . 51
nateglinide . . . . . . . . . . . 22
NAVANE . . . . . . . . . . . . 42
nedocromil . . . . . . . . . . 47
nefazodone hcl . . . . . . . . 39
nelfinavir . . . . . . . . . . . . 29
NEO DM . . . . . . . . . . . . 42
neomycin/polymyxin B/
bacitracin . . . . . . . . . 16
neomycin/polymyxin B/
dexamethasone . . . . . . 35
neomycin/polymyxin B/
gramicidin . . . . . . . . . 36
neomycin/polymyxin B/
hydrocortisone . . . . 19, 35
neomycin sulfate . . . . . . . 30
NEORAL . . . . . . . . . . . . . 6
NEOSPORIN . . . . . 16, 36, 56
NEO-SYNEPHRINE . . . 20, 56
NEPHROCAPS . . . . . . . . 51
NEPTAZANE . . . . . . . . . . 36
NESTABSCBF/FA/RX . . . . . 51
NEULASTA . . . . . . . . . . . .7
NEUMEGA . . . . . . . . . . . .7
NEURONTIN . . . . . . . . . . 15
NEUTROGENA OIL FREE
ACNE WASH . . . . . . . . 16
nevirapine . . . . . . . . . . . 29
nevirapine ER . . . . . . . . . 29
NEXAVAR . . . . . . . . . . . . .5
NEXIUM 24HR OTC . . . . . . 24
NEXIUM DELAYED
RELEASE PACKET . . . . 24
niacin . . . . . . . . . . . . . 10
niacin extended-release . . . 10
NIACINOL . . . . . . . . . . . 10
NIACOR . . . . . . . . . . . . 10
NIASPAN . . . . . . . . . . . . 10
nicardipine . . . . . . . . . . . 9
NICODERM CQ . . . . . 41, 58
NICORETTE OTC . . . . . . . 41
nicotine . . . . . . . . . . 41, 58
NICOTINE GUM . . . . . . . . 58
nicotine polacrilex gum . . . . 41
nicotine polacrilex lozenge . . 41
NICOTROL . . . . . . . . . . . 58
nifedipine . . . . . . . . . . . . 9
nifedipine extended-release . . 9
NIFEREX . . . . . . . 49, 50, 58
NIFEREX-PN FORTE . . . . . 51
nilotinib . . . . . . . . . . . . . 4
nimodipine . . . . . . . . . . . 9
NIMOTOP . . . . . . . . . . . . 9
NINLARO . . . . . . . . . . . . .5
nintedanib . . . . . . . . . . . 53
nitazoxanide suspension . . . 30
nitazoxanide tablet . . . . . . 30
NITREK . . . . . . . . . . . . 11
NITRO-BID . . . . . . . . . . . 11
NITRO-DUR . . . . . . . . . . 11
nitrofurantoin
extended-release . . . . . 30
nitrofurantoin macrocrystals . 30
ALL CAPS = Brand-name drug
Lower case = Generic drug
71
nitrofurantoin susp . . . . . . 30
nitroglycerin . . . . . . . .11, 18
NITROLINGUAL . . . . . . . . 11
NITROSTAT . . . . . . . . . . . 11
NIX . . . . . . . . . . . . . . . 57
NIX CREME RINSE . . . . . . 18
NIZORAL . . . . . . . . . 17, 28
NIZORAL SHAMPOO . . . . . 18
NOLVADEX . . . . . . . . . . . .5
NORCO . . . . . . . . . . . . . 13
NORDETTE . . . . . . . . . . 33
norelgestromin/EE . . . . . . 33
norethindrone . . . . . . . . . 33
norethindrone acetate . . . . 34
norethindrone acetate/EE32, 33
norethindrone acetate/
EE/iron . . . . . . . . . . 33
norethindrone/EE . . . . 32, 33
norethindrone/ME . . . . . . 33
NORFLEX . . . . . . . . . . . 32
norgestimate/EE . . . . . . . 33
norgestrel . . . . . . . . . . . 33
norgestrel/EE . . . . . . . . . 33
NORPACE . . . . . . . . . . . . 8
NORPACE CR . . . . . . . . . .8
NORPRAMIN . . . . . . . . . . 38
nortriptyline . . . . . . . . . . 38
NORVASC . . . . . . . . . . . . 9
NORVIR . . . . . . . . . . . . . 29
NOVOLIN . . . . . . . . . . . . 56
NOVOLIN 70/30 . . . . . . . . 22
NOVOLIN N . . . . . . . . . . 21
NOVOLIN R . . . . . . . . . . 21
NOVOLOG . . . . . . . . . . . 21
NOVOLOG MIX 70/30 . . . . 21
NUEDEXTA . . . . . . . . . . . 41
NULYTELY . . . . . . . . . . . 25
NUPLAZID . . . . . . . . . . . 40
NUTROPIN AQ NUSPIN . . . 23
NUVARING . . . . . . . . . . . 32
NYMALIZE . . . . . . . . . . . .9
nystatin . . . . . . . . . . 17, 28
NYTOL QUICK CAPS . . . . . 39
Index of Covered Drugs
O
OCEAN NASAL SPRAY . . . . 20
octreotide . . . . . . . . . . . . 6
OCUFEN . . . . . . . . . . . . 35
OCUFLOX . . . . . . . . . . . 36
ODOMZO . . . . . . . . . . . . .6
OFEV . . . . . . . . . . . . . . 53
ofloxacin . . . . . . . 19, 27, 36
OGEN . . . . . . . . . . . . . . 34
olanzapine . . . . . . . . . . . 41
olanzapine-fluoxetine . . . . . 40
olanzapine for IM inj . . . . . 40
olanzapine ODT . . . . . . . . 40
olanzapine pamoate for
extended rel IM sus . . . . 40
olaparib . . . . . . . . . . . . . 6
olodaterol . . . . . . . . . . . 47
olsalazine sodium . . . . . . . 25
omalizumab . . . . . . . . . . 47
omeprazole delayed-release 24
OMNICEF . . . . . . . . . . . . 27
ondansetron . . . . . . . . . . 24
ONE TOUCH SYSTEMS (ULTRA
2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ, VERIO
SYNC) . . . . . . . . . . . 22
ONE TOUCH TEST STRIPS
(ULTRA, VERIO) . . . . . . 22
ONFI . . . . . . . . . . . . . . 14
ONGLYZA . . . . . . . . . . . 22
oprelvekin . . . . . . . . . . . . 7
OPSUMIT . . . . . . . . . . . . 11
OPTIPRANOLOL . . . . . . . 35
OPTIVAR . . . . . . . . . . . . 34
ORAP . . . . . . . . . . . . . . 42
ORAPRED . . . . . . . . . . . 21
ORKAMBI . . . . . . . . . . . 52
orphenadrine
extended-release . . . . . 32
ORTHO-CEPT . . . . . . . . . 33
ORTHO COIL . . . . . . . . . 32
ORTHO-CYCLEN . . . . . . . 33
ortho diaphragm . . . . . . . 32
ORTHO EVRA . . . . . . . . . 33
ORTHO FLAT . . . . . . . . . 32
ORTHO FLEX . . . . . . . . . 32
ORTHO MICRONOR . . . . . 33
ORTHO-NOVUM 1/35 . . . . 33
ORTHO-NOVUM 1/50 . . . . 33
ORTHO-NOVUM 7/7/7 . . . . 33
ORTHO-NOVUM 10/11 . . . 32
ORTHO TRI-CYCLEN . . . . . 33
ORUDIS . . . . . . . . . . 12, 31
OS-CAL . . . . . . . . . . 49, 58
oseltamivir . . . . . . . . . . . 28
OVCON 50 . . . . . . . . . . . 33
OVIDE . . . . . . . . . . . . . . 18
OVRAL . . . . . . . . . . . . . 33
OVRETTE . . . . . . . . . . . . 33
oxaprozin . . . . . . . . . 12, 31
oxazepam . . . . . . . . . . . 37
oxcarbazepine . . . . . . . . 15
oxybutynin chloride . . . . . . 48
oxybutynin IR . . . . . . . . . 48
oxycodone . . . . . . . . . . 13
oxycodone/acetaminophen . 13
oxycodone/aspirin . . . . . . 13
OXYFAST . . . . . . . . . . . . 13
oxymetazoline . . . . . . . . . 20
oxymorphone ER . . . . . . . 13
OXYMORPHONE ER . . . . . 13
P
palbociclib . . . . . . . . . . . 5
paliperidone . . . . . . . . . . 41
paliperidone tab SR . . . . . 40
palivizumab . . . . . . . . . . 30
PAMELOR . . . . . . . . . . . 38
pancrelipase . . . . . . . . . 26
panobinostat . . . . . . . . . . 4
PANRETIN . . . . . . . . . . . .6
pantoprazole . . . . . . . . . 24
PARAFON FORTE DSC . . . . 32
PARNATE . . . . . . . . . . . . 38
paromomycin . . . . . . . . . 30
paroxetine . . . . . . . . . . . 38
paroxetine HCL tab SR . . . . 40
paroxetine mesylate tab . . . 40
PASER . . . . . . . . . . . . . 26
pasireotide . . . . . . . . . . . 6
ALL CAPS = Brand-name drug
Lower case = Generic drug
72
PAXIL . . . . . . . . . . . . . . 38
PAXIL CR . . . . . . . . . . . . 40
pazopanib . . . . . . . . . . . 5
PEDIACARE LIQ MULTI-SY . . 46
PEDIALYTE . . . . . . . . 49, 57
PEDIAPRED . . . . . . . . . . 21
PEDIAZOLE . . . . . . . . . . 27
peg 3350/electrolytes . . . . 25
peg 3350/sodium bicarbonate/
sodium chloride . . . . . 25
peg 3350/sodium
bicarbonate/sodium chloride/potassium chloride . 25
PEGASYS . . . . . . . . . . . . 28
PEGASYS PROCLICK . . . . 28
pegfilgrastim . . . . . . . . . . 7
peginterferon alfa-2a . . . . . 28
peginterferon alfa-2b . . . . . 5
pegvisomant . . . . . . . . . 23
penicillamine . . . . . . . . . 31
penicillin VK . . . . . . . . . . 27
PENLAC SOLUTION 8% . . . 17
PENTASA . . . . . . . . . . . . 25
pentazocine/naloxone . . . . 13
pentoxifylline extended-release 7
PEPCID . . . . . . . . . . . . . 24
PEPCID AC . . . . . . . . 24, 57
PERCOCET . . . . . . . . . . 13
PERCODAN . . . . . . . . . . 13
PERIDEX . . . . . . . . . . . . 21
perindopril erbumine . . . . . 7
permethrin . . . . . . . . 18, 57
perphenazine . . . . . . . . . 42
PERSANTINE . . . . . . . . . . 7
PEXEVA . . . . . . . . . . . . . 40
phenazopyridine . . . . . . . 48
phenelzine . . . . . . . . . . . 40
PHENERGAN . . . . . . . . . 24
PHENERGAN DM . . . . . . . 44
phenobarbital . . . . . . . . . 15
PHENOBARBITAL . . . . . . . 15
phenyleph/bromphen/dextromethorphan/guaifenesin 45
phenylephrine . . . . . . . . . 20
Index of Covered Drugs
phenylephrine/brompheniramine/dextromethorphan 45
phenylephrine/
chlorpheniramine . . . . . 45
phenylephrine/
chlorpheniramine/
dextromethorphan . . . . 45
phenylephrine/
chlorpheniramine/
dihydrocodeine . . . . . . 45
phenylephrine/
dextromethorphan . . . . 45
phenylephrine/dextromethorphan/guaifenesin . . . . 46
phenylephrine/ephed/CPM
w/carbetapentane . . . . 46
phenylephrine/guaifenesin . . 46
phenylephrine/hydrocodone/
guaifenesin . . . . . . . . 46
phenylephrine/pyrilamine/
dextromethorphan . . . . 46
phenylephrine/pyrilamine
w/hydrocodone . . . . . . 46
phenylephrine tan/pyrilamine
tan/carbeta tan . . . . . . 46
PHENYLHIST LIQ DH . . . . . 43
PHENYTEK . . . . . . . . . . . 15
phenytoin . . . . . . . . . . . 15
phenytoin sodium extended . 15
PHISOHEX . . . . . . . . . . . 18
PHOS-FLUR . . . . . . . . 49, 58
PHOSPHOLINE IODINE . . . 36
phosphorus . . . . . . . . . . 52
PHRENILIN . . . . . . . . . . . 12
phytonadione . . . . . . . . . 50
pilocarpine . . . . . . . . 21, 36
PILOPINE HS GEL . . . . . . . 36
PIMA . . . . . . . . . . . . . . 52
pimavanserin . . . . . . . . . 40
pimecrolimus . . . . . . . . . 19
pimozide . . . . . . . . . . . . 42
pindolol . . . . . . . . . . . . . 9
PINDOLOL . . . . . . . . . . . .9
pioglitazone . . . . . . . . . . 22
pioglitazone/glimepiride . . . 22
pioglitazone/metformin . . . 22
pioglitazone/metformin ER . 22
PIPERONYL BUTOXIDE . . . 57
piperonyl butoxide gel, liquid
shampoo . . . . . . . . . 57
pirfenidone capsule . . . . . 53
piroxicam . . . . . . . . . 12, 32
PLAN B . . . . . . . . . . . . . 32
PLAQUENIL . . . . . . . . 30, 31
PLAVIX . . . . . . . . . . . . . 7
PLENDIL . . . . . . . . . . . . . 9
plerixafor . . . . . . . . . . . . 7
PLETAL . . . . . . . . . . . . . .7
PLEXION . . . . . . . . . . . . 16
pneumococcal 13-valent
conjugate . . . . . . . . . 54
pneumococcal vaccine
polyvalent . . . . . . . . . 54
PNEUMOVAX . . . . . . . . . 54
PNEUMOVAX 23 . . . . . . . 54
podofilox . . . . . . . . . . . . 18
polyethylene glycol 3350 . . . 25
polymyxin B/bacitracin . . . . 36
polymyxin B/trimethoprim . . 36
polysaccharide iron complex 50
POLYSPORIN . . . . . . . . . 36
POLYTRIM . . . . . . . . . . . 36
POLY-VI-FLOR . . . . . . . . . 50
POLY-VI-SOL . . . . . . . . . . 58
pomalidomide . . . . . . . . . 5
POMALYST . . . . . . . . . . . .5
ponatinib . . . . . . . . . . . . 5
potassium acid phosphate . . 52
potassium bicarbonate/potassium citrate effervescent 52
potassium chloride . . . . . . 52
POTASSIUM CHLORIDE . . . 52
potassium chloride
extended-release . . . . . 52
potassium chloride ext-rel . . 52
potassium citrate . . . . . . . 48
potassium iodide . . . . . 46, 52
POTIGA . . . . . . . . . . . . . 15
povidone-iodine . . . . . . . . 30
PRALUENT . . . . . . . . . . . 10
ALL CAPS = Brand-name drug
Lower case = Generic drug
73
pramipexole . . . . . . . . . . 14
pramlintide . . . . . . . . . . 23
PRAMLYTE . . . . . . . . . . . 40
PRANDIN . . . . . . . . . . . . 22
praziquantel . . . . . . . . . . 26
prazosin . . . . . . . . . . . . . 8
PRECOSE . . . . . . . . . . . 22
PRED FORTE . . . . . . . . . 35
PRED-G . . . . . . . . . . . . . 35
PRED MILD . . . . . . . . . . 35
prednicarbate . . . . . . . . . 17
prednisolone . . . . . . . . . 21
prednisolone acetate . . . . . 35
prednisolone phosphate . . . 35
prednisolone sodium
phosphate . . . . . . . . . 21
prednisone . . . . . . . . . . 21
pregabalin . . . . . . . . . . . 15
PRELONE . . . . . . . . . . . 21
PREMARIN . . . . . . . . . . . 33
PREMPHASE . . . . . . . . . 34
PREMPRO . . . . . . . . . . . 34
prenatal vitamins w/folic acid 51
PRENATAL VITAMINS W/
FOLIC ACID . . . . . . . . 51
prenatal vit w/FE bisglyc-FE prot
succ-FA . . . . . . . . . . 51
prenatal vit w/FE bisglycinate
chelate-FA . . . . . . 50, 51
prenatal vit w/FE
polysac cmplx-FA . . . . . 51
prenatal vit w/iron
carbonyl-FA . . . . . . . . 51
prenatal w/o A w/FE carbonylFE gluc-DSS-FA . . . . . . 51
prenat-FE Bis-FE prot succ-FACA & omega 3 . . . . . . 50
prenat-FE bis-FE prot succ-FACA & omega DR . . . . . 50
prenat w/o A w/fecbn-fegl-DSSFA & DHA . . . . . . . . . 50
PREPARATION H . . . . . . . 57
PREVACID . . . . . . . . . . . 24
PREVIDENT . . . . . . . . . . 49
PREVNAR 13 . . . . . . . . . 54
Index of Covered Drugs
PREZCOBIX . . . . . . . . . . 30
PREZISTA . . . . . . . . . . . . 29
PRIFTIN . . . . . . . . . . . . . 26
PRILOSEC . . . . . . . . . . . 24
primaquine . . . . . . . . . . 30
primidone . . . . . . . . . . . 15
PRINCIPEN . . . . . . . . . . . 27
PRISTIQ . . . . . . . . . . . . . 39
PROAMATINE . . . . . . . . . 11
probenecid . . . . . . . . . . 32
PROBENECID . . . . . . . . . 32
PROBIOTIC FORMULA . . . . 26
probiotic product . . . . . . . 26
procarbazine . . . . . . . . . . 6
PROCARDIA . . . . . . . . . . .9
PROCARDIA XL . . . . . . . . .9
prochlorperazine . . . . . . . 24
PROCRIT . . . . . . . . . . . . .7
PROCTOSOL HC
CREAM 2.5% . . . . . . . 18
PROCTOZONE
CREAM-HC 2.5% . . . . . 18
progesterone inj . . . . . . . . 34
PROGESTERONE INJ . . . . 34
progesterone micronized . . . 34
PROGRAF . . . . . . . . . . . . 6
PROLIXIN . . . . . . . . . . . . 41
PROLIXIN DECANOATE . . . 41
PROMACTA . . . . . . . . . . 53
promethazine . . . . . . . . . 24
promethazine &
phenylephrine . . . . . . . 46
PROMETHAZINE SYP DM . . 44
PROMETHAZINE VC
W/CODEINE . . . . . . . . 44
PROMETHAZINE
W/CODEINE . . . . . . . . 44
PROMETH VC SYP . . . . . . 46
PROMETRIUM . . . . . . . . . 34
propafenone . . . . . . . . . . 8
propantheline . . . . . . . . . 48
propranolol . . . . . . . . . 9, 14
propranolol HCL . . . . . . . . 9
propranolol/HCTZ . . . . . . . 9
propylthiouracil . . . . . . . . 23
PROPYLTHIOURACIL . . . . . 23
PROSCAR . . . . . . . . . . . 48
PROSOM . . . . . . . . . . . . 39
PROTONIX . . . . . . . . . . . 24
PROTOPIC 0.1% . . . . . . . . 19
PROTOPIC 0.03% . . . . . . . 19
protriptyline . . . . . . . . . . 40
PROVENTIL . . . . . . . . . . 47
PROVERA . . . . . . . . . . . 34
PROZAC . . . . . . . . . . 38, 40
PROZAC WEEKLY . . . . . . . 40
PRUET DHAEC PAK . . . . . 50
PRUET DHA PAK
SETONET PAK . . . . . . 50
PSE/GG . . . . . . . . . . . . 44
pseudoephedrine/acetaminophen/dextromethorphan 46
pseudoephedrine/chlorpheniramine/dextromethorphan 46
pseudoephedrine/dextromethorphan/guaifenesin . . . . 46
pseudoephedrine/iburprofen 46
pseudoephedrine tan/ dexchlorphen tan/DM tan . . . . . 46
psyllium . . . . . . . . . . . . 57
PULMICORT RESPULES . . . 47
PULMOZYME . . . . . . . . . 52
PURINETHOL . . . . . . . . . . 4
pyrazinamide . . . . . . . . . 26
PYRAZINAMIDE . . . . . . . . 26
pyrethrins/piperonyl but. . . . 18
PYRIDIUM . . . . . . . . . . . 48
pyridostigmine . . . . . . . . 14
pyridostigmine
extended-release . . . . . 14
pyrilamine tan/phenyleph tan 47
pyrimethamine . . . . . . . . 30
Q
QUAL-TUSSIN SYP DC . 45, 46
QUESTRAN . . . . . . . . . . 10
QUESTRAN-LIGHT . . . . . . 10
quetiapine . . . . . . . . . . . 41
quetiapine fumarate tab SR . 40
quinapril . . . . . . . . . . . . . 8
ALL CAPS = Brand-name drug
Lower case = Generic drug
74
quinapril/hydrochlorothiazide . 8
quinidine gluconate
extended-release . . . . . . 8
QUINIDINE GLUCONATE
EXT-REL . . . . . . . . . . . 8
quinidine sulfate . . . . . . . . 8
QUINIDINE SULFATE . . . . . .8
quinidine sulfate
extended-release . . . . . . 9
QUINIDINE SULFATE EXT-REL 9
QV-ALLERGY . . . . . . . . . 43
R
raloxifene . . . . . . . . . . . 23
raltegravir . . . . . . . . . 30, 31
RANEXA . . . . . . . . . . . . 11
ranitidine . . . . . . . . . . . . 24
ranolazine . . . . . . . . . . . 11
RAPAMUNE . . . . . . . . . . . 6
RAVICTI . . . . . . . . . . . . . 53
RAZADYNE . . . . . . . . . . 12
REBETOL . . . . . . . . . . . . 28
REBIF . . . . . . . . . . . . . . 14
RECOMBIVAX HB . . . . . . . 53
rectal crm, suppositories . . . 57
RECTIV . . . . . . . . . . . . . 18
REGLAN . . . . . . . . . . . . 24
regorafenib . . . . . . . . . . . 5
REGRANEX . . . . . . . . . . 18
RELAFEN . . . . . . . . . . . . 31
RELENZA . . . . . . . . . . . . 28
RELION 70/30 . . . . . . . . . 22
RELION N . . . . . . . . . . . 21
RELION R . . . . . . . . . . . 21
REMERON . . . . . . . . . . . 39
REMERON SOLTAB . . . . . . 40
RENVELA . . . . . . . . . . . . 53
repaglinide . . . . . . . . . . 22
REQUIP . . . . . . . . . . . . . 14
RESCRIPTOR . . . . . . . . . 29
RESTORIL . . . . . . . . . . . 39
RETIN-A . . . . . . . . . . . . 16
RETROVIR . . . . . . . . . . . 29
REVATIO . . . . . . . . . . . . 11
REVIA . . . . . . . . . . . 37, 41
Index of Covered Drugs
REVLIMID . . . . . . . . . . . . 5
REXULTI . . . . . . . . . . . . 39
REYATAZ . . . . . . . . . . . . 29
REYATAZ POWDER PACKET 29
ribavirin . . . . . . . . . . . . 28
RIDAURA . . . . . . . . . . . . 31
RID SHAMPOO/
BUTOXIDE SHAMPOO . . 18
rifabutin . . . . . . . . . . . . 26
RIFADIN . . . . . . . . . . . . . 26
rifapentine . . . . . . . . . . . 26
rifapin . . . . . . . . . . . . . 26
rilpivirine . . . . . . . . . . . . 29
rimantadine . . . . . . . . . . 28
rimexolone . . . . . . . . . . . 35
riociguat . . . . . . . . . . . . 11
RISPERDAL . . . . . . . . . . 41
RISPERDAL CONSTA . . . . . 40
RISPERDAL CONSTA . . . . . 41
RISPERDAL M-TAB . . . . . . 40
RISPERDAL SOLUTION . . . 41
risperidone . . . . . . . . . . 41
risperidone microspheres
for inj . . . . . . . . . . . . 40
risperidone ODT . . . . . . . 40
risperidone oral soln . . . . . 41
RITALIN . . . . . . . . . . . . . 37
RITALIN LA . . . . . . . . . . . 38
RITALIN-SR . . . . . . . . . . . 38
ritonavir . . . . . . . . . . . . 29
rivaroxaban . . . . . . . . . . . 7
rivastigmine . . . . . . . . . . 12
rizatriptan . . . . . . . . . . . 13
RMS . . . . . . . . . . . . . . . 13
ROBAXIN . . . . . . . . . . . . 32
ROBINUL . . . . . . . . . . . . 25
ROBITUSSIN . . . . . . . 44, 56
ROBITUSSIN CF . . . . . 44, 56
ROBITUSSIN DM . . . . . 44, 56
ROBITUSSIN LIQ CGH/ALRG45
ROBITUSSIN LIQ
CGH/CLD . . . . . . . 43, 46
ROBITUSSIN LIQ
CGH/CONG . . . . . . . . 44
ROBITUSSIN LIQ HD/CHST . 46
ROBITUSSIN LIQ PED NGHT 46
ROBITUSSIN PE . . . . . 44, 56
ROBITUSSIN PED LIQ
CGH/COLD . . . . . . . . 43
ROBITUSSIN PED SYP . . . . 44
ROBITUSSIN SYP
CHST CNG . . . . . . . . . 44
ROBITUSSIN SYP MAX-ST . . 44
ROCALTROL . . . . . . . . . . 49
RONDEC DM . . . . . . . . . 45
RONDEC DROPS . . . . . . . 43
RONDEC SYRUP . . . . . 42, 43
ropinirole . . . . . . . . . . . 14
ROWASA . . . . . . . . . . . . 25
ROXICODONE . . . . . . . . . 13
R-TANNAMINE . . . . . . . . . 43
rufinamide . . . . . . . . . . . 15
ruxolitinib . . . . . . . . . . . . 5
RYNA-12 S . . . . . . . . . . . 47
RYNATAN PEDIATRIC SUSP . 43
RYNATUSS . . . . . . . . . . . 43
RYNATUSS PEDIATRIC SUSP46
RYTHMOL . . . . . . . . . . . .8
S
SABRIL SOLUTION . . . . . . 15
SALAC . . . . . . . . . . . . . 55
SALAGEN . . . . . . . . . . . 21
salicylic acid . . . . . . . 16, 17
salicylic acid 17%/
collodion . . . . . . . 18, 58
salicylic acid lotion 2% . . . . 55
saline nasal spray 0.65% . . . 20
SAL-TROPINE . . . . . . . . . 26
SANCTURA . . . . . . . . . . 48
SANDIMMUNE . . . . . . . . . .6
SANDOSTATIN . . . . . . . . . .6
SANTYL . . . . . . . . . . . . 18
SAPHRIS . . . . . . . . . . . . 39
sapropterin . . . . . . . . . . 23
sapropterin powder . . . . . . 23
saquinavir mesylate . . . . . . 29
sargramostim . . . . . . . . . . 7
SAVAYSA . . . . . . . . . . . . .6
saxagliptin . . . . . . . . . . . 22
ALL CAPS = Brand-name drug
Lower case = Generic drug
75
saxagliptin/metformin . . . . 22
SCALPICIN . . . . . . . . . . . 17
scopolamine . . . . . . . . . 36
SEASONALE . . . . . . . . . . 32
SECTRAL . . . . . . . . . . . . .9
SEDAPAP . . . . . . . . . . . . 12
selegiline . . . . . . . . . . . 14
selegiline td patch . . . . . . 40
selenium sulfide . . . . . . . . 19
SELSUN . . . . . . . . . . . . 19
SELZENTRY . . . . . . . . . . 30
sennosides . . . . . . . . . . 25
SENOKOT . . . . . . . . . . . 25
SENSIPAR . . . . . . . . . . . 53
SERAX . . . . . . . . . . . . . 37
SEROMYCIN . . . . . . . . . . 26
SEROQUEL . . . . . . . . . . 41
SEROQUEL XR . . . . . . . . 40
sertraline . . . . . . . . . . . . 38
SERZONE . . . . . . . . . . . 39
sevelamer . . . . . . . . . . . 53
SIGNIFOR . . . . . . . . . . . . 6
sildenafil . . . . . . . . . . . . 11
SILVADENE . . . . . . . . . . . 16
silver sulfadiazine . . . . . . . 16
simethicone . . . . . . . . . . 57
simvastatin . . . . . . . . . . . 10
SINEMET . . . . . . . . . . . . 14
SINEMET CR . . . . . . . . . . 14
SINEQUAN . . . . . . . . . . . 38
SINGULAIR . . . . . . . . . . . 48
sirolimus . . . . . . . . . . . . 6
SIRTURO . . . . . . . . . . . . 30
sodium chloride hypertonic . 37
sodium chloride
hypertonic ophth soln . . 37
sodium chloride irrigation soln
0.9% . . . . . . . . . . . . 54
sodium citrate/citric acid . . . 48
sodium phenylbutyrate oral
powder . . . . . . . . . . 53
sodium polysterene sulfonate 11
sofosbuvir . . . . . . . . . . . 28
sofosbuvir/velpatasvir . . . . 28
somatropin . . . . . . . . . . 23
Index of Covered Drugs
SOMAVERT . . . . . . . . . . 23
SONATA . . . . . . . . . . . . 39
sonidegib . . . . . . . . . . . . 6
sorafenib . . . . . . . . . . . . 5
SORIATANE . . . . . . . . . . 17
sotalol . . . . . . . . . . . . . . 9
SOVALDI . . . . . . . . . . . . 28
Spacers . . . . . . . . . . . . 53
spironolactone . . . . . . . . 10
spironolactone/
hydrochlorothiazide . . . 10
SPORANOX . . . . . . . . . . 28
SPRYCEL . . . . . . . . . . . . .4
SSKI . . . . . . . . . . . . . . . 46
STADOL . . . . . . . . . . . . 13
STARLIX . . . . . . . . . . . . 22
STATUSS DM SYP . . . . . . . 45
stavudine . . . . . . . . . . . 29
STELAZINE . . . . . . . . . . . 42
STIVARGA . . . . . . . . . . . . 5
stool softeners . . . . . . . . 57
STRENSIQ . . . . . . . . . . . 23
STRIBILD . . . . . . . . . . . . 29
STRIVERDI RESPIMAT . . . . 47
STROMECTOL . . . . . . . . . 26
STUART PRENATAL . . . . . . 58
SUBOXONE . . . . . . . . . . 41
SUBUTEX . . . . . . . . . . . 41
sucralfate . . . . . . . . . . . 24
sugar+orthophosphoric acid 57
sulcralfate . . . . . . . . . . . 24
sulfacetamide . . . . . . . . . 36
sulfacetamide/phenylephrine 36
sulfacetamide/pred phos . . 35
sulfacetamide sodium lotion 16
sulfacetamide/sulfur . . . . . 16
SULFACET-R . . . . . . . . . . 16
sulfamethoxazole/
trimethoprim, DS . . . . . 27
sulfasalazine . . . . . . . 25, 31
sulfasalazine
delayed-release . . . . 25, 31
sulindac . . . . . . . . . . 12, 32
sumatriptan . . . . . . . . . . 13
sumatriptan-naproxen . . . . 13
SUMYCIN . . . . . . . . . . . . 27
sunitinib . . . . . . . . . . . . . 5
SUPRAX . . . . . . . . . . . . 27
SURMONTIL . . . . . . . . . . 41
SUSTIVA . . . . . . . . . . . . 29
SUTENT . . . . . . . . . . . . . 5
SYLATRON . . . . . . . . . . . .5
SYMBYAX . . . . . . . . . . . 40
SYMLINPEN 60 . . . . . . . . 23
SYMMETREL . . . . . . . 14, 28
SYNAGIS . . . . . . . . . . . . 30
SYNALAR . . . . . . . . . . . 16
SYNJARDY . . . . . . . . . . . 22
SYNTHROID . . . . . . . . . . 23
T
TABLOID . . . . . . . . . . . . . 4
tacrolimus . . . . . . . . . . 6, 19
TAFINLAR . . . . . . . . . . . . 4
TAGAMET . . . . . . . . . . . 24
TALWIN NX . . . . . . . . . . . 13
TAMBOCOR . . . . . . . . . . .8
TAMIFLU . . . . . . . . . . . . 28
tamoxifen . . . . . . . . . . . . 5
tamsulosin . . . . . . . . . . . 48
TANAFED . . . . . . . . . . . . 43
TANAFED DMX
SUSPENSION . . . . . . . 46
TANZEUM . . . . . . . . . . . 23
TAPAZOLE . . . . . . . . . . . 23
TARCEVA . . . . . . . . . . . . .4
TARGRETIN . . . . . . . . . . . 6
TASIGNA . . . . . . . . . . . . .4
tasimelteon . . . . . . . . . . 40
TASMAR . . . . . . . . . . . . 14
TECFIDERA . . . . . . . . . . 14
teduglutide . . . . . . . . . . 26
TEGRETOL . . . . . . . . . . . 14
TEGRETOL-XR . . . . . . . . . 14
temazepam . . . . . . . . . . 39
TEMODAR . . . . . . . . . . . .4
TEMOVATE . . . . . . . . . . . 17
temozolomide . . . . . . . . . 4
TENEX . . . . . . . . . . . . . . 8
TENIVAC . . . . . . . . . . . . 54
ALL CAPS = Brand-name drug
Lower case = Generic drug
76
tenofovir . . . . . . . . . . . . 29
TENORETIC . . . . . . . . . . .9
TENORMIN . . . . . . . . . . . .9
TERAZOL 3/7 . . . . . . . . . 34
terazosin . . . . . . . . . . 8, 48
terbinafine . . . . . . . . 17, 28
terbutaline . . . . . . . . . . . 48
terconazole . . . . . . . . . . 34
teriflunomide . . . . . . . . . 14
teriparatide inj . . . . . . . . . 23
TESSALON . . . . . . . . . . . 42
TESTOSTERONE 1%
TOPICAL GEL . . . . . . . 21
testosterone cypionate . . . . 21
testosterone enanthate . . . . 21
testosterone gel topical tube,
packet, and pump bottle 21
tetanus-diphtheria toxoids . . 54
tetanus immune globulin . . . 54
TET/DIP TOX INJ . . . . . . . 54
tetrabenazine . . . . . . . . . 15
tetracaine hcl ophth soln . . . 37
tetracycline . . . . . . . . . . 27
tetrahydrozoline/zinc sulfate . 35
tet tox-diph-acell pertuss ad . 54
thalidomide . . . . . . . . . . . 6
THALOMID . . . . . . . . . . . .6
THEO-24 . . . . . . . . . . . . 48
THEOCHRON . . . . . . . . . 48
theophylline . . . . . . . . . . 48
THEOPHYLLINE . . . . . . . . 48
theophylline extended-release48
THEOPHYLLINE EXT-REL . . 48
THERA-PLUS . . . . . . . . . 50
thioguanine . . . . . . . . . . . 4
thioridazine . . . . . . . . . . 42
thiothixene . . . . . . . . . . . 42
THORAZINE . . . . . . . . . . 41
THORAZINE INJ . . . . . . . . 39
THYROLAR . . . . . . . . . . 23
tiagabine . . . . . . . . . . . . 15
TIAZAC . . . . . . . . . . . . . .9
TIGAN . . . . . . . . . . . . . . 24
TIKOSYN . . . . . . . . . . . . .8
TILADE . . . . . . . . . . . . . 47
Index of Covered Drugs
timolol . . . . . . . . . . . . . 35
timolol maleate . . . . . . . 9, 35
TIMOPTIC . . . . . . . . . . . 35
TIMOPTIC XE . . . . . . . . . 35
TINACTIN . . . . . . . . . 17, 55
tipranavir . . . . . . . . . . . . 29
TIVICAY . . . . . . . . . . . . . 30
tizanidine . . . . . . . . . . . 32
TOBRADEX . . . . . . . . . . 35
tobramycin . . . . . . . . . . 36
tobramycin/dexamethasone 35
tobramycin neb soln . . . . . 53
TOBREX . . . . . . . . . . . . 36
TOFRANIL . . . . . . . . . . . 38
TOFRANIL-PM . . . . . . . . . 40
tolazamide . . . . . . . . . . . 22
tolbutamide . . . . . . . . . . 23
TOLBUTAMIDE . . . . . . . . 23
tolcapone . . . . . . . . . . . 14
TOLINASE . . . . . . . . . . . 22
tolnaftate . . . . . . . . . 17, 55
tolterodine . . . . . . . . . . . 48
TOPAMAX . . . . . . . . . . . 15
TOPAMAX SPRINKLE . . . . . 15
topical antibacterials . . . . . 56
topiramate . . . . . . . . . . . 15
topiramate sprinkle caps . . . 15
topotecan . . . . . . . . . . . . 6
TOPROL XL . . . . . . . . . . . 9
TORADOL . . . . . . . . . . . 12
toremifene . . . . . . . . . . . 5
torsemide . . . . . . . . . . . 10
TOUJEO SOLOSTAR . . . . . 21
TRACLEER . . . . . . . . . . . 11
TRADJENTA . . . . . . . . . . 22
tramadol . . . . . . . . . . . . 12
trametinib . . . . . . . . . . . . 5
TRANDATE . . . . . . . . . . . .9
trandolapril . . . . . . . . . . . 8
tranexamic acid . . . . . . . . 34
TRANXENE . . . . . . . . . . . 37
tranylcypromine . . . . . . . . 38
trazodone . . . . . . . . . 39, 41
TRECATOR . . . . . . . . . . . 26
TRENTAL . . . . . . . . . . . . .7
tretinoin . . . . . . . . . . . 6, 16
TREXIMET . . . . . . . . . . . 13
triamcinolone . . . . . . . . . 21
triamcinolone acetonide . . . 17
triamcinolone nasal spray . . 20
triamterene/
hydrochlorothiazide . . . 10
TRIAVIL . . . . . . . . . . . . . 38
triazolam . . . . . . . . . . . . 39
TRI-FED X . . . . . . . . . . . . 46
trifluoperazine . . . . . . . . . 42
trifluridine . . . . . . . . . . . 36
trifluridine/tipiracil . . . . . . . 4
trihexyphenidyl . . . . . . . . 14
TRILAFON . . . . . . . . . . . 42
TRILEPTAL . . . . . . . . . . . 15
TRILYTE . . . . . . . . . . . . 25
trimethobenzamide . . . . . . 24
trimethoprim . . . . . . . . . . 31
TRIMETHOPRIM . . . . . . . . 31
trimipramine . . . . . . . . . . 41
TRI-NORINYL . . . . . . . . . 33
TRINTELLIX . . . . . . . . . . 41
TRIOTANN . . . . . . . . . . . 20
TRIOTANN PEDIATRIC SUSP 43
tripolidine/pseudoephedrine 47
TRIPROL/PSE SYP . . . . . . 47
TRI RX . . . . . . . . . . . . . 51
TRIUMEQ . . . . . . . . . . . . 30
TRI-VI-FLOR . . . . . . . . . . 51
TRI-VI-SOL . . . . . . . . 52, 58
TRIVORA . . . . . . . . . . . . 33
TRIZIVIR . . . . . . . . . . . . 29
TROJAN . . . . . . . . . . . . 56
trospium . . . . . . . . . . . . 48
TRUSOPT . . . . . . . . . . . 35
TRUST NATALCARE
PAK DHA . . . . . . . . . . 50
TRUVADA . . . . . . . . . . . . 29
T-STAT . . . . . . . . . . . . . 16
TUMS . . . . . . . . . . . 57, 58
TUSSI 12D S . . . . . . . . . . 46
TUSSI-12 S . . . . . . . . . . . 43
TUSSIN DM . . . . . . . . . . 44
TWINJECT . . . . . . . . . . . 52
ALL CAPS = Brand-name drug
Lower case = Generic drug
77
TYBOST . . . . . . . . . . . . 30
TYKERB . . . . . . . . . . . . . 4
TYLENOL . . . . . . . 12, 31, 58
TYLENOL W/CODEINE . . . 13
typhoid vaccine . . . . . . . . 54
U
ULORIC . . . . . . . . . . . . . 32
ULTRAM . . . . . . . . . . . . 12
ULTRAVATE . . . . . . . . . . 17
umeclidinium inhalation . . . 47
umeclidinium/vilanterol . . . 47
UNI-HIST DRO . . . . . . . . . 42
UNIPHYL . . . . . . . . . . . . 48
UNIRETIC . . . . . . . . . . . . 8
UNIVASC . . . . . . . . . . . . .7
urea 40% . . . . . . . . . . . 19
UREA 40% LOTION . . . . . . 19
URECHOLINE . . . . . . . . . 48
UREX . . . . . . . . . . . . . . 48
uridine . . . . . . . . . . . . . 23
UROCIT-K . . . . . . . . . . . 48
UROXATRAL . . . . . . . . . . 48
URSO . . . . . . . . . . . . . 26
ursodiol . . . . . . . . . . . . 26
URSO FORTE . . . . . . . . . 26
UTIRA C . . . . . . . . . . . . 48
V
vaginal products . . . . . . . 55
valacyclovir . . . . . . . . . . 28
VALCYTE . . . . . . . . . . . . 28
valganciclovir . . . . . . . . . 28
VALIUM . . . . . . . . . . 32, 37
valproic acid . . . . . . . . . . 15
VALTREX . . . . . . . . . . . . 28
VANCOCIN HCL . . . . . . . . 28
vancomycin HCl . . . . . . . 28
vandetanib . . . . . . . . . . . 5
VAQTA . . . . . . . . . . . . . 53
varenicline . . . . . . . . . . . 41
varicella virus vac live for
subcutaneous . . . . . . . 54
VARIVAX . . . . . . . . . . . . 54
VASERETIC . . . . . . . . . . . 8
Index of Covered Drugs
VASOCIDIN . . . . . . . . . . . 35
VASOCLEAR . . . . . . . . . . 35
VASOCLEAR A . . . . . . . . 35
VASOSULF . . . . . . . . . . . 36
VASOTEC . . . . . . . . . . . . .7
VECTICAL . . . . . . . . . . . 17
VEETIDS . . . . . . . . . . . . 27
vemurafenib . . . . . . . . . . 5
venlafaxine . . . . . . . . . . 38
venlafaxine HCL tab SR . . . 41
VENLAFAXINE HCL TAB SR . 41
venlafaxine XR . . . . . . . . 38
VENTOLIN HFA . . . . . . . . 47
VEPESID . . . . . . . . . . . . . 6
verapamil . . . . . . . . . . 9, 14
verapamil extended-release . . 9
VERSACLOZ . . . . . . . . . . 39
VESANOID . . . . . . . . . . . .6
VEXOL . . . . . . . . . . . . . 35
VFEND . . . . . . . . . . . . . 28
VIBRAMYCIN . . . . . . . . . . 27
VICODIN . . . . . . . . . . . . 13
VICODIN ES . . . . . . . . . . 13
VICTOZA . . . . . . . . . . . . 23
VI-DAYLIN . . . . . . . . . . . . 58
VIDEX . . . . . . . . . . . . . . 29
VIDEX EC . . . . . . . . . . . . 29
vigabatrin oral solution . . . . 15
VIIBRYD . . . . . . . . . . . . . 41
vilazodone . . . . . . . . . . . 41
VIMPAT . . . . . . . . . . . . . 15
VINATE AZ EX . . . . . . . . . 51
VINATE III . . . . . . . . . . . . 51
VIRACEPT . . . . . . . . . . . 29
VIRAMUNE . . . . . . . . . . . 29
VIRAMUNE XR . . . . . . . . . 29
VIREAD . . . . . . . . . . . . . 29
VIROPTIC . . . . . . . . . . . . 36
VISINE . . . . . . . . . . . . . 57
VISINE-AC . . . . . . . . . . . 35
vismodegib . . . . . . . . . . . 6
VISTARIL . . . . . . . . . . . . 19
VISTOGARD . . . . . . . . . . 23
VI-STRESS . . . . . . . . . . . 48
vitamin A . . . . . . . . . . . . 51
vitamin ADC/fluoride/±iron
drops . . . . . . . . . . . 51
vitamin B-1 . . . . . . . . . . 51
vitamin B-6 . . . . . . . . . . 51
VITAMIN B-12 . . . . . . . . . 49
vitamin B complex/
vitamin C/folic acid . . . . 51
vitamin C . . . . . . . . . . . 51
vitamin D . . . . . . . . . 52, 58
VITAMIN D . . . . . . . . . . . 58
vitamin E . . . . . . . . . . . . 52
vitamins pediatric . . . . 52, 58
vitamins prenatal . . . . . . . 58
VITAPHIL . . . . . . . . . . . . 50
VITUSSIN . . . . . . . . . . . . 45
VIVACTIL . . . . . . . . . . . . 40
VIVOTIF BERNA . . . . . . . . 54
VOLTAREN . . . . . . . . . . . 35
VOLTAREN 1% TOPICAL GEL31
voriconazole . . . . . . . . . . 28
vorinostat . . . . . . . . . . . . 4
vortioxetine . . . . . . . . . . 41
VOSOL HC OTIC . . . . . . . 19
VOSOL OTIC . . . . . . . . . . 19
VOSPIRE ER . . . . . . . . . . 47
VOTRIENT . . . . . . . . . . . . 5
VRAYLAR . . . . . . . . . . . . 39
VYVANSE . . . . . . . . . . . . 37
W
warfarin . . . . . . . . . . . . . 7
WELLBUTRIN . . . . . . . . . 38
WELLBUTRIN SR . . . . . . . 38
WELLBUTRIN XL . . . . . . . 38
WELLCOVORIN . . . . . . . . .6
WESTCORT . . . . . . . . . . 17
WYTENSIN . . . . . . . . . . . 11
ALL CAPS = Brand-name drug
Lower case = Generic drug
78
X
XALATAN . . . . . . . . . . . . 36
XALKORI . . . . . . . . . . . . .4
XANAX . . . . . . . . . . . . . 37
XARELTO . . . . . . . . . . . . .7
XELODA . . . . . . . . . . . . . 4
XENAZINE . . . . . . . . . . . 15
XOLAIR . . . . . . . . . . . . . 47
XOPENEX RESPULES . . . . 47
XYLOCAINE . . . . . . . . 18, 21
XYZAL . . . . . . . . . . . . . 20
Z
zaleplon . . . . . . . . . . . . 39
ZANAFLEX . . . . . . . . . . . 32
zanamivir . . . . . . . . . . . 28
ZANTAC . . . . . . . . . . . . 24
ZARONTIN . . . . . . . . . . . 15
ZAROXOLYN . . . . . . . . . . 10
ZARXIO . . . . . . . . . . . . . .7
ZEBETA . . . . . . . . . . . . . .9
ZELBORAF . . . . . . . . . . . .5
ZENPEP . . . . . . . . . . . . 26
ZEPATIER . . . . . . . . . . . . 28
ZERIT . . . . . . . . . . . . . . 29
ZESTORETIC . . . . . . . . . . .8
ZESTRIL . . . . . . . . . . . . . 7
ZETIA . . . . . . . . . . . . . . 11
ZIAC . . . . . . . . . . . . . . . .9
ZIAGEN . . . . . . . . . . . . . 29
zidovudine . . . . . . . . . . . 29
zinc . . . . . . . . . . . . . . . 52
ZINCATE . . . . . . . . . . . . 52
zinc sulfate . . . . . . . . . . 52
ziprasidone . . . . . . . . . . 41
ZITHROMAX . . . . . . . . . . 27
ZOCOR . . . . . . . . . . . . . 10
ZOFRAN . . . . . . . . . . . . 24
ZOFRAN ODT . . . . . . . . . 24
ZOHYDRO ER . . . . . . . . . 13
Index of Covered Drugs
ZOLINZA . . . . . . . . . . . . .4
ZOLOFT . . . . . . . . . . . . 38
zolpidem . . . . . . . . . . . . 39
ZONEGRAN . . . . . . . . . . 15
zonisamide . . . . . . . . . . 15
ZORTRESS . . . . . . . . . . . .6
ZOSTAVAX . . . . . . . . . . . 54
zoster vaccine live . . . . . . . 54
ZOVIA 1/35 . . . . . . . . . . 33
ZOVIA 1/50 . . . . . . . . . . 33
ZOVIRAX . . . . . . . . . . . . 28
ZYBAN . . . . . . . . . . . . . 41
ZYDELIG . . . . . . . . . . . . .4
ZYKADIA . . . . . . . . . . . . .4
ZYLOPRIM . . . . . . . . . . . 32
ZYMAR . . . . . . . . . . . . . 36
ZYPREXA . . . . . . . . . 40, 41
ZYPREXA RELPREVV . . . . 40
ZYPREXA ZYDIS . . . . . . . 40
ZYRTEC . . . . . . . . . . 20, 55
ZYRTEC D . . . . . . . . 20, 56
ZYTIGA . . . . . . . . . . . . . .5
ZYVOX . . . . . . . . . . . . . 30
ALL CAPS = Brand-name drug
Lower case = Generic drug
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Notes
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“My Medications” worksheet
Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of
every drug you take and you should have a list as well.
Name of Medicine
and Strength
Drug
Tier
I Take This
Medicine For
Directions
Doctor
Example: Lisinopril, 20mg
Tier 1
High blood pressure
One tablet daily
Dr. Johnson
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10/16