Abridged Drug Formulary MDF14
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2014 GLOBALHEALTH MAXIMUM PERFORMANCE ABRIDGED FORMULARY
Table of Contents Helpful Numbers .......................................................... 2 Types of Pharmacy Networks ...................................... 3 Prior Authorization ....................................................... 3 Step Therapy ............................................................... 3 Quantity Limits ............................................................. 3 Your Prescription Drug Benefits .................................. 4 Requesting an Exception ............................................. 4 Medication Therapy Management Program ................ 5 GlobalHealth’s Preferred Drug List .............................. 5 Therapeutic Class Index .............................................. 9 Alphabetical Listing Index .......................................... 48
The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of your Outpatient Prescription Drug Plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. You can get information and updates to this document at www.globalhealth.com.
Helpful Numbers and Information Plan Administrator: GlobalHealth, Incorporated PO Box 2328 Oklahoma City, OK 73101-2328 GlobalHealth Customer Care:
[email protected] 405.280.5600 (local) 1.877.280.5600 (toll-free) 1.800.522.8506 (TTY/TDD/Voice) www.globalhealth.com Language Assistance – just ask for an interpreter: 405.280.5600 (local) 1.877.280.5600 (toll-free) 1.800.722.0353 or 711 (TTY/TDD/Voice)
24/7 Nurse Help Line Nurse Help Line 1.877.280.2993 Disease Management Alere 1.855.894.7487 Behavioral & Mental Health/ Chemical Dependency: MHNet - 1.866.904.5234 1.866.200.3269 (TTY/TDD/Voice) GlobalHealth Compliance and Privacy Officer 1.877.280.5852 405.280.5852
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Pharmacy Benefits Manager: Mail Claims to: Express Scripts PO Box 66583 St. Louis, MO 63166 Express Scripts Help Desk: 1.866.274.1612 1.800.899.2114 (TTY/TDD/Voice) Mail Order Pharmacy: Express Scripts Customer Care Center 1.866.274.1612 1.800.899.2114 (TTY/TDD/Voice) 24 hours/7 days a week www.express-scripts.com
Types of Pharmacy Networks You have different options to receive your prescribed medications. Preferred Retail Network Pharmacy Your Copayment may be reduced by up to $5 per prescription when purchased at a preferred retail Network pharmacy when compared to a non-preferred retail Network pharmacy. You may still go to non-preferred retail Network pharmacies, but you won’t receive the discount. Both preferred and non-preferred retail Network pharmacies can be found on www.globalhealth.com find a pharmacy site. Home Delivery Pharmacy Service Express Scripts, Inc. (“ESI”) offers the convenience of home delivery. Maintenance medications are delivered in a 90-day supply. You may receive a discount on your medications, depending on the drug tier. See your Schedule of Benefits. Allow 10 days for your prescription to reach you. For more information about this optional service, contact ESI. Contact Express Scripts Customer Service:
1-866-274-1612
Representatives are available 24 hours a day, 7 days a week. Visit the website:
www.express-scripts.com
Extended Supply Retail Pharmacy Network You may receive up to a 90-day supply of a maintenance drug at an extended supply retail Network pharmacy for the applicable home delivery Copayment or Coinsurance. An extended supply retail Network pharmacy can be found on www.globalhealth.com find a pharmacy site. Sovereign Medical Solutions Medications by Mail Sovereign Medical Solutions is a Native American-owned retail pharmacy located in Oklahoma. It provides prescription medications to Native Americans. Complete the Native American Prescription Benefit Program Patient Enrollment form available on www.globalhealth.com and submit to Sovereign Medical Solutions. Proof of Native American status in one of the federally recognized tribes is required. Once Native American heritage is established with Sovereign Medical Solutions, Members may receive Copayment discounts. Medications are mailed directly to the Member’s home or designated location. Specialty Pharmacy Our contracted specialty pharmacy fills your specialty medications and delivers them to your home. Specialty medications sent to and administered by your doctor are covered under your office visit cost-sharing responsibility. Specialty medications sent to and administered by you are assessed your prescription drug Copayment or Coinsurance. A specialty Network pharmacy can be found on www.globalhealth.com find a pharmacy site.
Prior Authorization, Step Therapy, Quantity Limits, and Exceptions Your Plan may include prior authorization, step therapy, or quantity limit requirements. These programs are based on current medical findings, FDA (U.S. Food and Drug Administration) approved manufacturer labeling information, cost, and manufacturer rate agreements. Prior Authorization: Physicians are required to obtain prior authorization for certain medications, to promote appropriate, cost-effective use. Any corresponding supplies or equipment also require prior authorization. Without prior authorization, GlobalHealth will not cover the drug, supply, or equipment. Step Therapy: Step therapy requires one or more prerequisite, clinically equivalent drugs to be tried before a step therapy drug will be covered. Quantity Limits: For certain drugs there are limits to the amount of the medication that you may receive. These drugs, if taken inappropriately for too long a time period, could be unsafe and cause adverse effects. 3
PLEASE NOTE: Not all the drugs listed are covered by all Prescription Drug benefit programs; check your Schedule of Benefits for specific exclusions and the Copayments for your Prescription Drug benefit program. For specific questions about your coverage, please call the phone number printed on your Member ID card. For the Member: Generic medications contain the same active ingredients in the same amounts as brand name products. However, they may be a different color, shape, or size. You will pay the lowest Copayment for generics. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.
Your Prescription Drug Benefits How to use your prescription drug benefits: 1. Fill your prescription at any GlobalHealth participating pharmacy. A list of Network pharmacies can be found in the GlobalHealth Physician & Health Providers Directory and on the website at www.globalhealth.com. You may also call Customer Care for help in locating a pharmacy. 2.
Present your GlobalHealth Member ID card to the pharmacist.
3.
Pay the applicable Copayment.
Affordable Care Act Medicines to promote better health as recommended under the Patient Protection and Affordable Care Act: Iron supplements: For children from age 6 months through 12 months Oral fluoride supplements: For children from age 6 months through 5 years Folic acid supplements: For women capable of pregnancy Aspirin: For men age 45 through 79 and women age 55 through 79 To receive benefits, you must use an in-network retail pharmacy and present a written prescription from your physician to the pharmacist. Benefits are limited to recommended prescribed limits. Contraception Drugs and Devices For Women Selected FDA-approved contraception prescriptions are provided with no cost-sharing. All others are subject to prescription Copayment or Coinsurance and possible prior authorization. Certain over-the-counter contraceptives are covered with a prescription. Contraceptives which are provided for no cost-sharing are indicated by an X in the PCL column. See the Drug Formulary to see which prescription contraceptives are provided for no cost-sharing. Prescriptions Received in an Emergency Room or Urgent Care Facility Medications prescribed by ER physicians may be filled at either a preferred Network or a non-preferred Network pharmacy. You will pay your pharmacy cost-share. Pharmacy Coordination of Benefits Coordination of benefits for pharmacy benefits is handled the same as for medical benefits. See, “When You Are Covered by More Than One Plan”, in your Member Handbook.
Requesting an Exception You can request GlobalHealth to waive coverage restrictions and limits. Generally, GlobalHealth will only approve your request for an exception if: the alternative drug is included on GlobalHealth’s formulary; the drug in a lower category or additional utilization restrictions would not be as effective in treating your condition; and/or, would cause you to have adverse medical effects. You or your physician should contact GlobalHealth for instructions on obtaining an initial coverage decision for a utilization restriction exception. Your physician may have to submit a prior authorization request form, with information supporting the request for an exception. Generally, a decision is made within 72 hours of your request. 4
Medication Therapy Management Program If you are taking multiple medications for Chronic Conditions, you can receive support from our Medication Therapy Management program. Enrollment in this program is automatic. You receive personalized service from registered pharmacists and staff. The goal of this program is to help eliminate duplicate drug therapies, reduce potential for negative drug interactions and side effects, and optimize Member benefits by advising of the lowest cost alternatives.
GlobalHealth’s Preferred Drug List The GlobalHealth preferred drugs are listed in this Drug Formulary. Medications on the list are selected based on quality (effectiveness and safety) as well as cost-effectiveness. Doctors and pharmacists have worked together to develop the formulary, which includes generics and brand name medications that are approved by the FDA. The list of drugs is subject to change. Please check your Schedule of Benefits for detailed information regarding your drug coverage, benefit limitations, and exclusions. For specific questions about your coverage, please call the phone number printed on your Member ID card. Tier One Copayment: Generic medications contain the same active ingredients in the same amounts as brand name products. However, they may be a different color, shape, or size. If your Plan has a Copayment for Prescription Drugs, you will pay the lowest Copayment for generics. There may be an even lower Copayment for certain low-cost generic drugs. Please refer to your Schedule of Benefits. Tier Two Copayment: Preferred brand name medications on the Formulary have the next highest cost. Tier Three Copayment: Non-preferred brand name medications have the highest cost of these three tiers. Tier Four Copayment: Specialty medications are filled through a specialty pharmacy. You will receive a one-month supply. These medications must be pre-approved by GlobalHealth. Refer to your Schedule of Benefits. Lists of medications included in the low-cost generic program and specialty medications are available on our website. Please contact Customer Care for printed versions of these medication lists. In addition to using the Drug Formulary, you are encouraged to ask your doctor to prescribe generics when possible. Generics not only save you money, they also help GlobalHealth continue to offer prescription coverage at such reasonable rates. The Copayments must be met each time a Prescription Drug is filled or refilled. You will pay the Copayment or the cost of the Prescription Drug, whichever is less. Please contact Customer Care if you need assistance locating a pharmacy, understanding your benefits, or printed copies of the formulary.
[email protected] (405) 280-5600 (local) 1-877-280-5600 (toll free) 1-800-722-0353 or 711 (TTY/TDD/Voice) Monday – Friday, 9 am – 5 pm
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GLOBALHEALTH 2014 DRUG FORMULARY INDEX THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, 2014. THIS LIST IS SUBJECT TO CHANGE. You can get information and updates to this document at www.globalhealth.com. KEY The symbol [PCL] next to a drug name indicates that the drug is on the preventive care list. The symbol [LCG] next to a drug name indicates that the drug is a Low Cost Generic. The symbol [INJ] next to a drug name indicates that the drug is an Injectable. The symbol [OTC] next to a drug name indicates that the drugs is available Over-the-Counter. The symbol [ST] next to a drug name indicates that Step Therapy may apply to some or all strengths of the drug. The symbol [PA] next to a drug name indicates that prior authorization is required. The symbol [QLL] next to a drug name indicates quantities limited. The symbol [*] next to a drug signifies subject to non-preferred status when generic is available throughout the year. Brand name drugs are listed in CAPITAL letters. Example: CELEBREX Generic drugs are listed in lower case letters. Example: ibuprofen
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Patient Protection and Affordable Care Act Preventive Items and Services The Patient Protection and Affordable Care Act (PPACA) imposes a number of insurance reforms and mandates including a requirement to cover certain preventive items and services at 100 percent and ensure these items and services are not subject to deductibles or other costsharing limitations. The following list of preventive medications should be used as a guide. It cannot be considered a comprehensive listing of medications available or covered without cost- sharing. Coverage of any of the listed medications (including over-the-counter (OTC) medications) requires a prescription from a licensed health care provider. This list is subject to change as ACA guidelines are updated or modified. Members: The terms of your health plan will ultimately determine coverage and cost-sharing. For specific questions about your coverage, please call the phone number printed on your ID card. You can get more information and updates to this document at our website at www.express-scripts.com. Aspirin products ASPIRIN 81 MG and 325 MG Fluoride products MULTIVITAMIN W/ FLUORIDE CHEWABLE 0.25 MG and 0.5 MG DROPS 0.25 MG and 0.5 MG SUSPENSION
FLUORIDE CHEWABLE TABLET 0.25 MG and 0.5 MG FLUORIDE DROPS 0.125, 0.25 MG and 0.5 MG
Iron Supplements IRON (various strengths) DROPS, LIQUID, SUSPENSION, GRANULES
MULTIVITAMIN WITH IRON DROPS, LIQUID, SUSPENSION
Folic Acid Products FOLIC ACID TABLET 0.4 MG and 0.8 MG (0.4 MG and 0.8 MG)
PRENATAL and MULTI VITAMINS W/ FOLIC ACID
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Immunizations Covered immunizations include those that are routine vaccines recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and that meet the US Food and Drug Administration approved indications for age and/or gender limitations. Coverage also includes immunizations used to prevent illnesses associated with travel such as typhoid, yellow fever, and Japanese encephalitis. Contraceptive Methods Covered products include OTC contraceptive methods (female condom, spermicides, etc.), oral contraceptives (including emergency contraception), and contraceptive devices (diaphragms, skin patch systems, injectable contraception, intrauterine systems, and implants). Please note: brand name contraceptives that have a generic equivalent are available at a zero cost share only when the prescriber indicates that the brand product must be dispensed. Smoking Cessation Products BUPROPION SR 150 MG CHANTIX NICOTINE GUM, LOZENGE and PATCH (Over-The-Counter products only) Vitamin D Supplements VITAMIN D 1,000 UNITS OR LESS PER DOSE UNIT CALCIUM WITH VITAMIN D Bowel Preps (limit of 2 prescriptions per year) BISACODYL MAGNESIUM CITRATE MILK OF MAGNESIA PEG 3350-ELECTROLYTE Please note: coverage of brand name medications is dependent on the terms of your health plan.
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Therapeutic Class Index 2014 GLOBALHEALTH HIGH PERFORMANCE ABRIDGED FORMULARY TABLE OF CONTENTS Chapter Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17 Chapter 18
Name ANESTHETICS ANTIINFECTIVES ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS CARDIOVASCULAR MEDICATIONS AUTONOMIC & CNS MEDICATIONS DERMATOLOGICAL MEDICATIONS EAR-NOSE-THROAT MEDICATIONS ENDOCRINE MEDICATIONS GASTROINTESTINAL MEDICATIONS IMMUNOLOGICALS & VACCINES MUSCULOSKELETAL MEDICATIONS NUTRITION, BLOOD OBSTETRICAL & GYNECOLOGICAL MEDICATIONS OPHTHALMIC MEDICATIONS RESPIRATORY MEDICATIONS UROLOGICAL MEDICATIONS DIAGNOSTIC & MISCELLANEOUS MEDICATIONS MEDICAL (MISCELLANEOUS) SUPPLIES
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
FB
NFB
PCL
CHAPTER 1: ANESTHETICS 1.2 TOPICAL ANESTHETICS
lidocaine hcl lidocaine-prilocaine LIDODERM
X X PA X CHAPTER 2: ANTIINFECTIVES
lidocaine
2.1.1 CEPHALOSPORINS
cefaclor/er cefadroxil cefdinir cefpodoxime proxetil cefprozil cefuroxime cephalexin
X X X X X X X
CEDAX
X
CEFTIN
X
SUPRAX
X 9
cefpodoxime, cefuroxime, cefdinr cefpodoxime, cefuroxime, cefdinr cefpodoxime, cefuroxime, cefdinr
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
FB
NFB
PCL
2.1.3 CLINDAMYCINS
clindamycin hcl clindamycin phosphate
X X
2.1.4 ERYTHROMYCINS
erythromycin ERY-TAB
X X
2.1.4.1 OTHER MACROLIDES
azithromycin clarithromycin/er
X X
2.1.5 PENICILLINS
amox tr-potassium clavulanate amoxicillin 125mg/5mL, 400mg/5mL syrup; 250mg cap; 875mg tab amoxicillin amoxicillin-clavulanate er dicloxacillin 500mg cap dicloxacillin penicillin v potassium 250, 500mg tab; 250mg/5mL susp penicillin v potassium
X X X X X X X X
2.1.6 SULFONAMIDES
sulfamethoxazole-trimethoprim DS sulfamethoxazole-trimethoprim
X X
2.1.7 TETRACYCLINES
doxycycline hyclate 50, 100mg tab doxycycline hyclate/monohydrate minocycline hcl tetracycline hcl 250, 500mg cap tetracycline hcl DORYX ORACEA SOLODYN
X X X X X ST ST ST
X X X
doxycycline hyclate DR doxycycline hyclate minocycline hcl
X
ciproflox, levoflox, ofloxacin
2.1.8 URINARY ANTIINFECTIVES
nitrofurantoin/mono-macro trimethoprim
X X
2.1.9 QUINOLONES
ciprofloxacin er ciprofloxacin hcl 500mg tab ciprofloxacin hcl levofloxacin ofloxacin
X X X X X
AVELOX/ABC PACK 10
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
FB
NFB
PCL
FACTIVE LEVAQUIN
X X
NOROXIN
X
ciproflox, levoflox, ofloxacin levofloxacin ciproflox, levoflox, ofloxacin
X X
mupirocin mupirocin
X X X
griseofulvin microsize itraconazole capsules gen nystat, clotrimazol troch
X X X X
ciclopirox, ketoconazole econazole, ketoconazole ciclopirox, ketoconazole ciclopirox, ketoconazole
2.2 TOPICAL ANTIBACTERIAL DRUGS
gentamicin sulfate mupirocin silver sulfadiazine ALTABAX BACTROBAN
X X X
2.3 ORAL ANTIFUNGAL DRUGS
fluconazole 150mg tab fluconazole griseofulvin itraconazole ketoconazole nystatin terbinafine hcl voriconazole GRIFULVIN V ONMEL
X X X X X X X X
ORAVIG 2.4.1 VAGINAL ANTIFUNGALS
clotrimazole terconazole
X X
2.4.2 OTHER TOPICAL ANTIFUNGALS
ciclopirox clotrimazole econazole nitrate ketoconazole nystatin ERTACZO EXELDERM NAFTIN OXISTAT
X X X X X
2.4.3 TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB.
clotrimazole-betamethasone nystatin-triamcinolone
X X
2.5.1 ANTIRETROVIRALS & PROTEASE INHIBITORS
abacavir lamivudine
X X 11
DRUG NAME
TIER LCG
lamivudine-zidovudine nevirapine ATRIPLA COMBIVIR COMPLERA EPIVIR SOLUTION EPIVIR TABLET EPZICOM INCIVEK INTELENCE ISENTRESS KALETRA LEXIVA NORVIR PREZISTA REYATAZ STRIBILD SUSTIVA TRUVADA VICTRELIS VIRAMUNE VIRAMUNE XR VIREAD ZIAGEN SOLUTION ZIAGEN TABLET
SUGGESTED PREFFERED ALTERNATIVES
G
FB
NFB
PCL
X X SP SP SP SP SP SP PA, SP SP SP SP SP SP SP SP SP SP SP PA, SP SP SP SP SP SP
X X X
lamivudine/zidovudine ATRIPLA
X X X X X X X X X X X X X X X X
nevirapine
X
abacavir
X
ZOVIRAX OINTMENT
X
valacyclovir
X X
acyclovir + hydrocortisone acyclovir
X X X
2.5.2 OTHER ANTIVIRAL DRUGS
acyclovir amantadine famciclovir ribapak ribavirin valacyclovir BARACLUDE DENAVIR EPIVIR HBV RELENZA TAMIFLU VALCYTE VALTREX
X X X X X X
SP SP
X SP
X X X X
2.6 TOPICAL ANTIVIRAL DRUGS
XERESE ZOVIRAX 2.7.2 ANTITUBERCULOSIS DRUGS 12
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
isoniazid rifampin
G
FB
NFB
PCL
X X
2.7.3 PLASMODICIDES
atovaquone-proguanil hcl hydroxychloroquine sulfate mefloquine hcl MALARONE QUALAQUIN
X X X X X
atovaquone/proguanil hcl quinine sulfate
X X
metronidazole vancomycin
2.7.4 SULFONES
DAPSONE
X
2.7.5 TRICHOMONOCIDES
metronidazole tinidazole
X X
2.8 OTHER ANTIINFECTIVE DRUGS
vancomycin hcl DIFICID VANCOCIN HCL XIFAXAN ZYVOX
X
X X
PA
2.8.2 AMINOGLYCOSIDES
gentamicin sulfate X tobramycin sulfate X TOBI PA, SP X CHAPTER 3: ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS 3.0 ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
anagrelide hcl anastrozole azathioprine bicalutamide cyclosporine modified exemestane hydroxyurea leflunomide letrozole leucovorin calcium inj leucovorin calcium tabs megestrol acetate mercaptopurine methotrexate mycophenolate mofetil tacrolimus tamoxifen citrate temozolomide
X X X X X X X X X X X X X X X X X X
SP
SP
SP SP SP PA, SP 13
DRUG NAME
TIER LCG
tretinoin ARIMIDEX CELLCEPT CIMZIA ELIGARD ENBREL FEMARA GLEEVEC HUMIRA MEGACE ES MYFORTIC NEORAL ORENCIA PROGRAF amp PROGRAF caps RAPAMUNE REVLIMID SANDOSTATIN LAR SIMPONI SOMATULINE DEPOT STELARA TEMODAR TYKERB XELJANZ XELODA ZYTIGA
SUGGESTED PREFFERED ALTERNATIVES
G
FB
NFB
PCL
X
PA, SP
X X X
anastrozole
X
letrozole
X
megestrol acetate
ENBREL, HUMIRA
X X
PA/QLL/SP
PA, SP PA, SP PA, SP
X X
SP X SP X cyclosporine PA, SP X SP X SP X tacrolimus SP X PA, SP X SP X PA, SP X ENBREL, HUMIRA SP X SANDOSTATIN LAR ST X ENBREL, HUMIRA PA, SP X PA, SP X SP X ENBREL, HUMIRA, ORENCIA SC SP X SP X CHAPTER 4: CARDIOVASCULAR MEDICATIONS
4.1 CARDIAC GLYCOSIDES
digoxin LANOXIN
X X
digoxin
X X
IR nicardipine diltiazem 24 hr er
4.2 CALCIUM ANTAGONISTS
amlodipine besylate cartia xt diltiazem/er felodipine er nifediac cc nifedical xl nifedipine er nisoldipine verapamil verapamil/er pm CARDENE SR CARDIZEM LA
X X X X X X X X X X ST 14
DRUG NAME
TIER LCG
SULAR
SUGGESTED PREFFERED ALTERNATIVES
G
ST
FB
NFB
PCL
X
nisoldipine er
X X X
atenolol,carvedil,metoprol er carvedilol metoprolol succinate er
X
alfuzosin er, tamsulosin
4.3.1 LOOP DIURETICS
bumetanide furosemide torsemide
X X X
4.3.2 THIAZIDE AND RELATED DRUGS
chlorthalidone hydrochlorothiazide 25mg tab hydrochlorothiazide indapamide metolazone
X X X X X
4.3.3 POTASSIUM SPARING DIURETICS
amiloride hcl eplerenone spironolactone spironolactone-hctz triamterene-hctz
X X X X X
4.4 BETA-ADRENERGIC ANTAGONIST DRUGS
acebutolol hcl atenolol 25mg tab atenolol bisoprolol fumarate carvedilol labetalol hcl metoprolol succinate metoprolol tartrate 50mg tab metoprolol tartrate nadolol pindolol propranolol hcl timolol maleate
X X X X X X X X X X X X X
BYSTOLIC COREG CR TOPROL XL 4.5.1 VASODILATOR ANTIHYPERTENSIVES
doxazosin mesylate minoxidil prazosin hcl terazosin hcl CARDURA XL
X X X X
4.5.2 CENTRALLY ACTING ANTIHYPERTENSIVES
clonidine/hcl
X 15
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
guanfacine hcl methyldopa
G
FB
NFB
PCL
X X
4.5.4.1 ANGIOTENSIN CONVERTING ENZYME INHIBITORS
benazepril hcl captopril enalapril maleate fosinopril sodium lisinopril 10 & 20mg tab lisinopril moexipril hcl quinapril hcl ramipril trandolapril
X X X X X X X X X X
4.5.4.2 ANGIOTENSIN II RECEPTOR ANTAGONISTS
eprosartan mesylate irbesartan losartan potassium 25, 50, 100mg losartan potassium ATACAND/HCT AVALIDE AVAPRO
X X X X X X X
BENICAR/HCT COZAAR DIOVAN DIOVAN HCT EDARBI HYZAAR
X X
candesartan/hctz irbesartan/hctz irbesartan losartan/hctz, valsartan/hctz losartan
X X X X
MICARDIS/HCT
X
TEVETEN/HCT
X
4.5.6 OTHER ANTIHYPERTENSIVES
amlodipine besylate-benazepril atenolol-chlorthalidone benazepril-hydrochlorothiazide bisoprolol-hydrochlorothiazide candesartan-hydrochlorothiazid captopril-hydrochlorothiazide enalapril-hydrochlorothiazide fosinopril-hydrochlorothiazide irbesartan-hydrochlorothiazide lisinopril-hctz 20-25mg tab
X X X X X X X X X X 16
valsartan/hctz losartan, DIOVAN losartan/hctz losartan/hctz, valsartan/hctz losartan/hctz, valsartan/hctz
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
lisinopril-hydrochlorothiazide losartan-hydrochlorothiazide metoprolol-hydrochlorothiazide moexipril-hydrochlorothiazide quinapril-hydrochlorothiazide valsartan-hydrochlorothiazide AMTURNIDE
G
FB
NFB
PCL
X X X X X X X
AZOR
X
gen ace/arb+hctz+amlodipine amlod+losar or DIOVAN, EXFORGE
EDARBYCLOR EXFORGE/HCT LOTREL
X
losartan/hctz, valsartan/hctz
X X
TARKA
X
TEKAMLO TEKTURNA/HCT TRIBENZOR TWYNSTA
X X X X
amlodipine/benazepril verapamil er + trandolapril gen ace inh/arb+ amlodipine ace inh, losartan, hct amlodi+losartn-hct, EXFORGE amlodipine+losartn, EXFORGE
4.6.1 NITRATES
isosorbide/dinitrate nitroglycerin/patch NITROSTAT
X X X
4.6.2 OTHER VASODILATING DRUGS
sildenafil (pulmonary hypertension) ADCIRCA BIDIL REVATIO
PA, SP PA, SP
X X
PA, SP
X X
PA, SP PA, SP
X X
isosorbide dn + hydralazine sildenafil (pulmonary htn)
4.6.3 ENDOTHELIN RECEPTOR ANTAGONIST
LETAIRIS TRACLEER 4.7.1.3 CLASS 1C
flecainide acetate propafenone hcl RYTHMOL SR
X X X
propafenone er
X
amiodarone hcl
4.7.3 AMIODARONES
amiodarone hcl
X
4.7.5 OTHER ANTIARRHYTHMICS
sotalol MULTAQ TIKOSYN
X X
4.8.1 HYPOLIPOPROTEINEMICS 17
DRUG NAME
TIER LCG
cholestyramine colestipol hcl fenofibrate fenofibric acid gemfibrozil ANTARA FENOGLIDE LIPOFEN LOVAZA NIASPAN TRICOR TRIGLIDE TRILIPIX VASCEPA WELCHOL ZETIA
SUGGESTED PREFFERED ALTERNATIVES
G
FB
NFB
PCL
X X X X X
PA
PA
X X X X X X X X
fenofibrate fenofibrate fenofibrate VASCEPA niacin fenofibrate fenofibrate fenofibrate
X
cholestyramine
X X X X X
atorvastatin, simvastatin atorvastatin, simvastatin fluvastatin, generics atorvastatin atorvastatin, simvastatin
X X X X X
lovastatin + NIASPAN amlodipine/atorvastatin atorvastatin + ZETIA simvastatin + NIASPAN simvastatin + ZETIA
X X
4.8.2 HMG-COA REDUCTASE INHIBITORS
atorvastatin calcium fluvastatin sodium lovastatin pravastatin sodium 10, 20, 40mg pravastatin sodium simvastatin 5, 10, 20, 40mg simvastatin ALTOPREV CRESTOR LESCOL/XL LIPITOR LIVALO
X X X X X X X
4.8.2.1 HMG-COA COMBINATIONS
amlodipine-atorvastatin ADVICOR CADUET LIPTRUZET SIMCOR VYTORIN
X
4.9 OTHER CARDIOVASCULAR DRUGS
pentoxifylline RANEXA
X gen beta blocker, ccb, X nitrate CHAPTER 5: AUTONOMIC AND CNS MEDICATIONS
5.1.1 ANALGESICS
butorphanol tartrate
X 18
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
tramadol hcl/er tramadol hcl-acetaminophen
G
FB
NFB
PCL
X X
5.1.1.1 CLASS II NARCOTICS
endocet fentanyl hydromorphone hcl methadone hcl morphine sulfate/er oxycodone hcl oxycodone-acetaminophen oxymorphone hcl roxicet tabs ROXICET solution
X X X X X X X X X
QLL
QLL
X
X X
oxycodone solution fentanyl citrate OTFC lozenge morph sul er, OPANA ER, OXYCONTIN generics, OPANA ER, OXYCONTIN fentanyl citrate OTFC lozenge morph sul er, OPANA ER, OXYCONTN fentanyl citrate OTFC lozenge oxycodone, tramadol OPANA ER, OXYCONTIN fentanyl citrate OTFC lozenge oxymorphone
X
fentanyl citrate OTFC lozenge
X X
fentanyl patch buprenorphine-naloxone
ABSTRAL
PA
X
AVINZA
ST/QLL
X
EXALGO
ST
X
FENTORA
PA/QLL ST/PA/QL L
X
LAZANDA NUCYNTA NUCYNTA ER
PA
X X X
ONSOLIS OPANA OPANA ER OXYCONTIN
PA/SP/QLL
SUBSYS
PA
KADIAN
X
ST
ST ST/QLL
X X
5.1.1.2 CLASS III NARCOTICS
acetaminophen-codeine buprenorphine hcl buprenorphine-naloxone hydrocodone bit-ibuprofen hydrocodone-acetaminophen reprexain zamicet BUTRANS SUBOXONE
X X X X X X X
PA
19
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
ZUBSOLV
FB
NFB
X
PCL
gener sl tabs,SUBOXONE FILM
5.1.1.3 CLASS IV NARCOTICS
buprenorphine hcl
X
5.1.2 DRUGS TO PREVENT AND TREAT HEADACHES
butalbital compound-codeine butalbital-aspirin-caffeine naratriptan hcl rizatriptan sumatriptan zolmitriptan
X X X X X X
AXERT
X
FROVA IMITREX MAXALT/MLT MIGRANAL
X X X X
RELPAX SUMAVEL DOSEPRO
X X
TREXIMET ZOMIG/ZMT
X X
naratriptan,sumatrip,zolmi tri naratriptan,sumatrip,zolmi tri sumatriptan rizatriptan/odt ZOMIG NASAL naratriptan,sumatrip,zolmi tri sumatriptan vial sumatriptan tab + naproxen zolmitriptan/odt
5.2.1 ANXIOLYTICS
alprazolam/er/xr buspirone hcl chlordiazepoxide hcl clorazepate dipotassium diazepam lorazepam oxazepam
X X X X X X X
5.2.2 SEDATIVE/HYPNOTIC DRUGS
estazolam flurazepam hcl temazepam triazolam zaleplon zolpidem tartrate/er AMBIEN/CR
X X X X X X X
EDLUAR
X
INTERMEZZO
X 20
zolpidem/er zolpidem immediate release zolpidem immediate release
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
LUNESTA ROZEREM
FB
NFB
X
PCL
zolpidem immediate release
X
SILENOR
X
ZOLPIMIST
X
zolpidem immediate release zolpidem immediate release
X X
carbamazepine er carbamazepine xr
5.3 ANTIMANIA DRUGS
lithium carbonate
X
5.4.1 CARBAMAZEPINES
carbamazepine/xr oxcarbazepine CARBATROL TEGRETOL XR
X X
5.4.2 ANTICONVULSANT BENZODIAZEPINES
clonazepam diazepam ONFI
X X X
5.4.3 HYDANTOINS
phenytoin sodium extended
X
DILANTIN
X
PHENYTEK
X
phenytoin sodium extended phenytoin sodium extended
X
divalproex sodium er
X X X
gabapentin gabapentin levetiracetam/er
5.4.4 VALPROIC ACID AND DERIVATIVES
divalproex sodium/er valproic acid DEPAKOTE ER
X X
5.4.6 ANTICONVULSANT BARBITURATES
phenobarbital primidone
X X
5.4.7 OTHER ANTICONVULSANTS
felbamate gabapentin lamotrigine levetiracetam topiramate 15mg sprinkle topiramate zonisamide 50mg cap zonisamide GRALISE HORIZANT KEPPRA/XR
X X X X X X X X ST ST
21
DRUG NAME
TIER LCG
LAMICTAL/ODT/XR LYRICA POTIGA TOPAMAX VIMPAT
SUGGESTED PREFFERED ALTERNATIVES
G
ST
FB
NFB
PCL
X
lamotrigine
X
topiramate
X X X
escitalopram generic SSRI generic SSRI
X X
venlafax er caps duloxetine venlafax er caps
X X
PA PA
X
5.5.1.1 TERTIARY AMINES
amitriptyline hcl 10, 25, 50, 75, 100, 150mg tab amitriptyline hcl clomipramine hcl doxepin hcl 10, 25, 50, 100mg cap doxepin hcl imipramine hcl 10, 25, 50mg tab imipramine hcl
X X X X X X X
5.5.1.2 SECONDARY AMINES
desipramine hcl nortriptyline hcl
X X
5.5.1.3 SELECTIVE SEROTONIN REUPTAKE INHIBITORS
citalopram hbr 10, 20, 40mg tab citalopram hbr escitalopram oxalate fluoxetine 10, 20mg cap; 10mg tab fluoxetine hcl fluvoxamine maleate paroxetine hcl 10, 20mg tab paroxetine hcl sertraline hcl 25, 50, 100mg tab sertraline hcl LEXAPRO LUVOX CR VIIBRYD
X X X X X X X X X X
5.5.1.4 OTHER ANTIDEPRESSANTS
bupropion hcl/sr/xl duloxetine mirtazapine trazodone hcl 50, 100, 150mg tab trazodone hcl venlafaxine hcl 25mg tab venlafaxine hcl venlafaxine hcl er caps VENLAFAXINE HCL ER tabs CYMBALTA EFFEXOR XR
X X X X X X X X X
22
DRUG NAME
TIER LCG
PRISTIQ ER SAVELLA WELLBUTRIN XL
SUGGESTED PREFFERED ALTERNATIVES
G
FB
NFB
PCL
X
venlafax er caps
X
bupropion xl
X X X
oral granisetron or ondansetrn
X X X X X X
selegiline entacapone pramipexole pramipexole, ropinirole/er ropinirole er ropinirole er carbidopa/levodopa/entac apone
X PA
5.5.2 MAO INHIBITORS
tranylcypromine sulfate
X
5.6 ANTIVERTIGO AND ANTIEMETIC DRUGS
dronabinol granisetron hcl meclizine hcl ondansetron hcl ondansetron odt prochlorperazine maleate promethazine hcl promethegan EMEND SANCUSO TRANSDERM-SCOP ZUPLENZ
X X X X X X X X X meclizine ondansetron odt
5.7.1 ANTIPARKINSON ANTICHOLINERGIC DRUGS
benztropine mesylate trihexyphenidyl hcl
X X
5.7.2 OTHER ANTIPARKINSON DRUGS
bromocriptine mesylate carbidopa-levodopa carbidopa-levodopa-entacapone entacapone pramipexole dihydrochloride ropinirole hcl AZILECT COMTAN MIRAPEX MIRAPEX ER NEUPRO REQUIP XL
X X X X X X
STALEVO
X
5.8 ANTIPSYCHOTIC DRUGS
clozapine fluphenazine hcl haloperidol 1mg tab haloperidol olanzapine olanzapine odt
X X X X X X 23
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
perphenazine quetiapine fumarate 25mg tab quetiapine fumarate risperidone 2mg tab risperidone thioridazine hcl thiothixene trifluoperazine hcl ziprasidone hcl ABILIFY/DISCMELT
G
FB
NFB
PCL
X X X X X X X X X X
FANAPT GEODON
X X
INVEGA
X
LATUDA RISPERDAL CONSTA
X
generic, ABILIFY/DISC,SEROQL XR ziprasidone generic, ABILIFY/DISC,SEROQL XR generic, ABILIFY/DISC,SEROQL XR
X X
generic, ABILIFY/DISC,SEROQL XR quetiapine fumarate
X X
olanzapine olanzapine odt
X
olanzapine/fluoxetine hcl
X
SAPHRIS SEROQUEL SEROQUEL XR ZYPREXA ZYPREXA ZYDIS
X
5.8.1 ALIPHATIC PHENOTHIAZINES
chlorpromazine hcl
X
5.8.1.1 PSYCHOTHERAPEUTIC COMBINATIONS
olanzapine-fluoxetine hcl SYMBYAX
X
5.9.1 CNS STIMULANT DRUGS
amphetamine salt combo dexmethylphenidate hcl dextroamphetamine 5mg tab dextroamphetamine sulfate dextroamphetamine-amphetamine methylin 5, 10mg tab methylin methylin er 20mg tab methylin er methylphenidate er-la methylphenidate hcl 5, 10mg methylphenidate hcl/er/sr modafinil
X X X X X X X X X X X X X
PA 24
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
FB
NFB
PCL
ADDERALL XR CONCERTA
ST ST
X X
DAYTRANA
ST
X
FOCALIN XR METADATE CD NUVIGIL PROVIGIL
ST ST PA PA
X X X X
QUILLIVANT XR RITALIN LA VYVANSE
ST ST ST
X X
dextroamphetamineamphetamine er methylphenidate er methylphenidate cd, er,VYVANSE methylphenidate cd, er,VYVANSE methylphenidate cd modafinil modafinil methylphenidate cd, VYVANSE methylphenidate er
X X X
donepezil donepezil odt rivastigmine
X
NAMENDA IR TABS
X
5.9.2 OTHER CNS/AUTONOMIC DRUGS
atropine sulfate naltrexone hcl pyridostigmine bromide NUEDEXTA
X X X X
5.9.3 ANTIDEMENTIA DRUGS
donepezil hcl galantamine hbr rivastigmine ARICEPT ARICEPT ODT EXELON NAMENDA NAMENDA XR
X X X
X
5.9.4 DRUGS TO TREAT MULTIPLE SCLEROSIS
AMPYRA GILENYA
PA, SP PA, SP
X X
5.9.5 SMOKING CESSATION PRODUCTS
bupropion hcl sr 150mg nicotine gum, lozenge, patch CHANTIX
X X X
5.9.6 OTHER DRUGS FOR ADHD
INTUNIV KAPVAY STRATTERA
ST
X
methylphenidate er generic clonidine(imm release)
ST X ST X CHAPTER 6: DERMATOLOGICAL MEDICATIONS
6.1 TOPICAL CORTICOSTEROID DRUGS
alclometasone dipropionate
X 25
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
betamethasone dipropionate betamethasone valerate clobetasol emollient clobetasol propionate desonide desoximetasone fluocinolone acetonide fluocinonide fluticasone propionate halobetasol propionate hydrocortisone hydrocortisone butyrate hydrocortisone valerate mometasone furoate triamcinolone acetonide CLOBEX CLODERM CORDRAN HALOG
G
FB
NFB
PCL
X X X X X X X X X X X X X X X X X X X
KENALOG LOCOID/LIPOCREAM
X X
OLUX/-E PRAMOSONE/E
X X
ULTRAVATE PAC
clobetasol propionate betamethson,flucinolone,triamc betamethson,flucinolone,triamc betmet dp crm/oint,desoxi .25%
triamcinolone (non aerosol) hydrocortisone buty clobetasol propionate crm,oint hydrocort 2.5/pramoxine 1% crm
X
halobetasol propionate crm
X X
clindamycin-benzoyl peroxide tretinoin
6.2 ANTIPRURITIC DRUGS
hydroxyzine
X
6.3 ANTIACNE DRUGS
adapalene benzoyl peroxide clindamycin phosphate clindamycin-benzoyl peroxide erythromycin erythromycin-benzoyl peroxide metronidazole sodium sulfacetamide-sulfur tretinoin tretinoin microsphere
X X X X X X X X X X
ACANYA ATRALIN 26
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
FB
NFB
PCL
BENZACLIN DIFFERIN
X X
DUAC
X
EPIDUO FINACEA METROGEL RETIN-A MICRO/PUMP VELTIN ZIANA
X X X X X X
clindamycin-benzoyl peroxide adapalene 0.1% crm clindamycin/benzoyl peroxide adapalene gel+benzoyl peroxide metronidazole topical metronidazole cream tretinoin clindamycin-bp gel tretinoin + clindamycin
X
podofilox
6.3.1 ACCUTANES
isotretinoin
X
6.7 KERATOLYTIC DRUGS
podofilox CONDYLOX
X
6.8 ANTIPSORIASIS AND ANTIECZEMA DRUGS
calcipotriene calcitrene selenium sulfide sulfacetamide sodium
X X X X
DOVONEX SORILUX
X X
TACLONEX TAZORAC VECTICAL
X
calcipotriene ointment, soln calcipotriene calcipotriene + betamethasone
X
calcipotriene oint
X
6.9.2 TOPICAL DERMATOLOGICAL DRUGS
fluorouracil imiquimod tretinoin CARAC ELIDEL EPICERAM FLUOROPLEX PICATO PROMISEB PROTOPIC SANTYL SOLARAZE
X X X
X
fluorouracil 5% cream, soln PROTOPIC emulsion sb, tl-cermide fluorouracil, imiquimod fluorouracil, imiquimod selenium sulfide, sod sulfacet
X
fluorouracil 5% cream,
X X X X X
ST
ST
X X 27
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
FB
VEREGEN ZYCLARA
NFB
PCL
X X
soln imiquimod, podofilox imiquimod
X
permethrin
6.9.3 SCABICIDES
malathion permethrin 5% EURAX ULESFIA
X X X
6.9.5 TOPICAL ANTI-INFLAMMATORY DRUGS
FLECTOR PENNSAID VOLTAREN
ST X ORAL NSAIDS ST X ORAL NSAIDS ST X ORAL NSAIDS CHAPTER 7: EAR-NOSE-THROAT MEDICATIONS
7.1 DRUGS AFFECTING THE EAR
antipyrine-benzocaine neomycin-polymyxin-hc neomycin-polymyxin-hydrocort ofloxacin CETRAXAL CIPRO HC CIPRODEX
X X X X X X
ciprofloxacin 0.2% otic CIPRODEX
X X X X X X X X X X X X
azelastine azelastine flunisolide,fluticasone azelastine + fluticasone triamcinolone acetonide flunisolide,fluticasone flunisolide,fluticasone azelastine, ASTEPRO flunisolide,fluticasone flunisolide,fluticasone flunisolide,fluticasone flunisolide,fluticasone
X
7.2 DRUGS AFFECTING THE NOSE
azelastine hcl flunisolide fluticasone propionate ipratropium bromide triamcinolone acetonide ASTELIN ASTEPRO BECONASE AQ DYMISTA NASACORT AQ NASONEX OMNARIS PATANASE QNASL RHINOCORT AQUA VERAMYST ZETONNA
X X X X X
ST ST ST ST ST ST ST ST ST
7.3 DRUGS AFFECTING THE THROAT AND MOUTH
cevimeline hcl doxycycline hyclate pilocarpine hcl
X X X 28
DRUG NAME
TIER LCG
triamcinolone acetonide
SUGGESTED PREFFERED ALTERNATIVES
G
FB
NFB
PCL
X CHAPTER 8: ENDOCRINE MEDICATIONS
8.1.1 INSULIN
APIDRA/SOLOSTAR HUMALOG products HUMULIN products LANTUS LANTUS SOLOSTAR LEVEMIR/FLEXPEN NOVOLIN products NOVOLOG products
QLL QLL QLL QLL QLL QLL QLL QLL
X
HUMALOG
X X
HUMULIN HUMALOG
X X X X
metformin hcl er metformin hcl er nateglinide + metformin repaglinide
X
pioglitazone/metformin
X X X X X
8.1.2 ORAL HYPOGLYCEMIC DRUGS
acarbose glimepiride 1, 2, 4mg tab glimepiride glipizide 5, 10mg tab glipizide glipizide er 2.5, 5mg tab glipizide er glipizide xl 2.5, 5, 10mg tab glipizide xl glipizide-metformin 5-500mg tab glipizide-metformin glyburide 1.25, 2.5, 5mg tab glyburide glyburide micro 1.5, 3, 6mg tab glyburide micro glyburide-met 1.25-250mg tab glyburide-metformin metformin hcl 500, 850, 1000mg metformin hcl metformin er 500mg tab metformin er nateglinide FORTAMET GLUMETZA PRANDIMET PRANDIN RIOMET
X X X X X X X X X X X X X X x X X X X X X X ST ST
ST
X
8.1.3 INSULIN SENSITIZERS
pioglitazone hcl pioglitazone-metformin ACTOPLUS MET
X X ST 29
DRUG NAME
TIER LCG
ACTOPLUS MET XR ACTOS AVANDAMET AVANDARYL AVANDIA DUETACT
SUGGESTED PREFFERED ALTERNATIVES
G
ST ST SP, ST SP, ST SP, ST ST
FB
NFB
PCL
X X X X X X
pioglitazone pioglitazone/glimepiride pioglitazone/glimepiride pioglitazone pioglitazone/glimepiride
X
BYDUREON, BYETTA
8.1.4 AMYLIN ANALOGUES
SYMLINPEN 120 SYMLINPEN 60
X X
8.1.5.1 INCRETIN MIMETICS
BYDUREON BYETTA VICTOZA 2-PAK/3-PAK
PA PA PA
X X
JANUMET/XR JANUVIA JENTADUETO
ST ST ST
X X X
KAZANO
ST
X
KOMBIGLYZE XR NESINA ONGLYZA
ST ST ST
X X X
OSENI TRADJENTA
ST ST
X
JANUMET/XR, JENTADUETO metform+JANUVorTRADJE NT,JANUMT JANUVIA, TRADJENTA JANUVIA,TRADJENTA pioglitazne+JANUVIA or TRADJENTA
X
IR prednisone
8.1.5.2 DIPEPTIDYL PEPTIDASE-IV INHIBITORS
X
8.1.6 SOD-GLUC CO-TRANSPTR 2 INHIB
GLUCAGEN
X
8.2 GLUCOSE ELEVATING DRUGS
GLUCAGEN GLUCAGON EMERGENCY KIT
X X
8.3.1 GLUCOCORTICOID DRUGS
dexamethasone dexamethasone sodium phosphate hydrocortisone methylprednisolone prednisolone prednisolone sodium phosphate prednisone 20mg tab prednisone veripred 20 RAYOS
X X X X X X X X X
8.3.2 MINERALOCORTICOID DRUGS 30
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
fludrocortisone acetate
G
FB
NFB
PCL
X
8.4.1 THYROID SUPPLEMENTS
levothyroxine sod 50, 100mcg tab levothyroxine sodium liothyronine westhroid ARMOUR THYROID CYTOMEL SYNTHROID
X X X X X X X
liothyronine levothyroxine sodium
X X X X
alendronate tab alendronate tab alendronate,ibandronate alendronate tab
X
alendronate tab
8.4.2 ANTITHYROID DRUGS
methimazole propylthiouracil
X X
8.6 OTHER ENDOCRINE DRUGS
alendronate sodium calcitonin nasal spray desmopressin acetate etidronate disodium ibandronate sodium zoledronic acid ACTONEL ATELVIA BINOSTO BONIVA tabs FORTEO FOSAMAX PLUS D SENSIPAR
X X X X X X
SP
QLL
QLL PA, SP
X
X CHAPTER 9: GASTROINTESTINAL MEDICATIONS
9.2 ANTIDIARRHEAL DRUGS
diphenoxylate-atropine
X
9.3 ANTISPASMODICS/DRUGS AFFECT GI MOTILITY
chlordiazepoxide-clidinium dicyclomine hcl hyoscyamine sulfate metoclopramide hcl
X X X X
9.4 ANTIULCER DRUGS
cimetidine 300/400/800mg tab, 300 mg/5 mL solution famotidine 40mg tab, 40mg/5 mL sol nizatidine 150/300mg cap, 15mg/mL sol ranitidine hcl 300mg cap/tab, 15mg/mL syrup
X X X X 31
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
FB
NFB
PCL
9.4.1 OTHER ANTIULCER DRUGS
misoprostol sucralfate CARAFATE
X X X
sucralfate
X X X X X X X
rabeprazole generics generics generics lansoprazole pantoprazole sodium generics
9.4.2 PROTON PUMP INHIBITORS
lansoprazole 30mg omeprazole 10, 40mg omeprazole-sodium bicarbonate pantoprazole sodium rabeprazole ACIPHEX DEXILANT ESOMEPRAZOLE STRONTIUM NEXIUM PREVACID PROTONIX ZEGERID
X X X
ST X ST ST ST
X
ST ST ST ST
9.4.3 HELICOBACTER PYLORI DRUGS
HELIDAC
X
OMECLAMOX-PAK
X
PREVPAC
X
PYLERA
X
bismuth+metronidaz+tetra cyclin omeprazole + clarithromycin + amox amox+clarithromyc+lansop razole metronidazole + tetracycline
X
peg 3350-electrolyte
X
hydrocortisone/pramoxine
9.5 LAXATIVES AND CATHARTICS
OSMOPREP 9.6 OTHER GI DRUGS
anucort-hc balsalazide disodium budesonide ec hydrocortisone hydrocortisone acetate pancrelipase 5,000 peg 3350-electrolyte proctosol-hc proctozone-hc sulfasalazine sulfasalazine dr trilyte with flavor packets ursodiol ANALPRAM ADVANCED
X X X X X X X X X X X X X
32
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
FB
NFB
PCL
ANALPRAM E
X
ANALPRAM HC APRISO ASACOL HD CANASA COLYTE WITH FLAVOR PACKS CREON DELZICOL DIPENTUM GOLYTELY HALFLYTELY-BISACODYL LIALDA MOVIPREP
X
cream hydrocortisone/pramoxine cream hydrocortisone/pramoxine cream
X
balsalazide, APRISO
X
peg 3350-electrolyte
X X X X X X X X
balsalazide, APRISO balsalazide, APRISO peg 3350-electrolyte peg 3350-electrolyte balsalazide, APRISO peg 3350-electrolyte peg-3350 w/flavor packs soln CREON
X X
CREON peg 3350-electrolyte
X X X
mesalamine 4 gm/60 ml enema
X QLL
X X
NULYTELY WITH FLAVOR PACKS PANCREAZE PENTASA PERTZYE PREPOPIK RECTIV RELISTOR SFROWASA SUCLEAR SUPREP
X
X X
ULTRESA ZENPEP
X X
peg 3350-electrolyte peg 3350-electrolyte pancrelipase dr 5000u CREON pancrelipase dr
X
LINZESS
9.7 IRRITABLE BOWEL DRUGS
AMITIZA LINZESS
X CHAPTER 10: IMMUNOLOGICALS AND VACCINES
10.0 IMMUNOLOGICALS AND VACCINES
ZOSTAVAX age restrictions apply
X
not all vaccines are available at all pharmacies
10.2.3 INTERFERONS
AVONEX AVONEX ADMINISTRATION PACK AVONEX PEN BETASERON COPAXONE EXTAVIA
PA, SP PA, SP PA, SP PA, SP PA, SP PA, SP
X X X X X X 33
AVONEX, BETASERON,
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
FB
NFB
PCL
REBIF PEGASYS/PROCLICK PEGINTRON/REDIPEN REBIF/REBIDOSE
PA, SP PA, SP PA, SP
X X
PEGASYS
X X X X X X
TEV-TROPIN TEV-TROPIN TEV-TROPIN TEV-TROPIN TEV-TROPIN TEV-TROPIN
X
ORENCIA
X
10.2.4 GROWTH HORMONES AND RELATED DRUGS
GENOTROPIN HUMATROPE NORDITROPIN FLEXPRO/NORDIFLEX NUTROPIN/AQ/AQ NUSPIN OMNITROPE SAIZEN TEV-TROPIN
PA, SP PA, SP PA, SP PA, SP PA, SP PA, SP PA, SP
X
10.2.6 INTERLEUKIN RECEPTOR ANTAGONIST
ACTEMRA prefilled syringe KINERET
PA, SP PA, SP
X
10.2.7 IMMUNOGLOBULIN ANTIBODIES
XOLAIR
PA, SP X CHAPTER 11: MUSCULOSKELETAL MEDICATIONS
11.1.1 SALICYLATES AND RELATED DRUGS
aspirin aspirin ec choline mag trisalicylate diflunisal salsalate
X X X X X
11.1.2 NON-STEROIDAL ANTIINFLAMMATORY AGENTS
diclofenac potassium diclofenac sodium etodolac 200mg cap etodolac flurbiprofen ibuprofen 400, 600, 800mg tab indomethacin 25mg cap indomethacin ketoprofen 50mg cap ketoprofen ketorolac 10mg tab; 30mg/mL vial ketorolac meloxicam nabumetone
X X X X X X X X X X X X X X X
naproxen 375, 500mg tab; 125mg/5mL susp
naproxen/sodium oxaprozin piroxicam
X X X 34
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
sulindac CAMBIA CELEBREX DUEXIS NAPRELAN SPRIX VIMOVO
G
FB
NFB
PCL
X ST
X
diclofenac potassium
X X X X
ibuprofen plus famotidine generics ketorolac tablets naproxen + omeprazole
X ST ST ST
11.2 DRUGS TO PREVENT AND TREAT GOUT
allopurinol probenecid COLCRYS ULORIC
X X X X
11.3.1 DIRECT MUSCLE RELAXANTS
baclofen tizanidine hcl
X X
11.3.2 CNS MUSCLE RELAXANTS
chlorzoxazone cyclobenzaprine hcl 10mg tab cyclobenzaprine hcl metaxalone methocarbamol orphenadrine citrate AMRIX SKELAXIN SOMA
X X X X X X X X X CHAPTER 12: NUTRITION,BLOOD
IR cyclobenzaprine metaxalone metaxalone, tizanidine
12.1.2 VITAMINS & MINERALS & RELATED PRODUCTS
BIFERA RX CEREFOLIN
X X
hemetab folic acid
12.1.3 THERAPEUTIC VITAMINS & MINERALS
calcitriol calcium acetate calcium with vitamin d eliphos folic acid levocarnitine vitamin d 1,000 units or less per dose unit DEPLIN HECTOROL NASCOBAL
X X X X X X X X X X
PHOSLYRA
X 35
folic acid calcitriol cyanocobalamin inj calcium acetate caps, ELIPHOS
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
FB
ZEMPLAR
NFB
PCL
X
calcitriol
X
NEUTRAL SODIUM FLUORIDE
X
WARFARIN SODIUM
X X X
fondaparinux sodium enoxaparin, fondaparinux enoxaparin
X
clopidogrel
X
tranexamic acid
X X X
RENVELA LACTULOSE calcium acetate, RENVELA
12.1.4 FLUORIDE PRODUCTS
ludent fluoride sodium fluoride
X X
PREVIDENT 12.2 POTASSIUM SUPPLEMENTS
potassium chloride
X
12.3.1 ORAL ANTICOAGULANTS, VITAMIN K
warfarin sod 1, 2.5, 3, 4, 5mg tab warfarin sodium COUMADIN
X X
12.3.2 HEPARIN AND HEPARIN ANTAGONISTS
enoxaparin sodium fondaparinux sodium heparin sodium ARIXTRA FRAGMIN LOVENOX
SP SP
X X X
SP SP SP
12.3.3 OTHER DRUGS AFFECTING COAGULATION
ELIQUIS XARELTO
X X
12.3.5 THROMBIN INHIBITORS
PRADAXA
X
12.4 ANTIPLATELET DRUGS
cilostazol clopidogrel dipyridamole AGGRENOX BRILINTA EFFIENT PLAVIX
X X X X X X
12.5 HEMOSTATICS
LYSTEDA 12.7 BLOOD DETOXICANTS
enulose lactulose FOSRENOL KRISTALOSE RENAGEL RENVELA
X X
X
12.8 NUTRITIONAL/SUPPLEMENT PRODUCTS
CEREFOLIN NAC
X 36
DRUG NAME
TIER LCG
FOLTX
SUGGESTED PREFFERED ALTERNATIVES
G
FB
NFB
PCL
X CHAPTER 13: OBSTETRICAL & GYNECOLOGICAL MEDICATIONS
13.1.1 PRENATAL VITAMINS
PREFERA OB PREFERA-OB ONE
X X
PREFERA-OB PLUS DHA
X
PRENATE DHA
X
PRENATE ELITE
X
PRENATE ESSENTIAL
X
hemenatal ob tabs prenatal mv & min capsule hemenatal ob+dha combo pk generic Rx prenatal vitamans generic Rx prenatal vitamans generic Rx prenatal vitamans
X X
CLINDAMYCIN 2% VAGINAL CREAM CLEOCIN, CLINDAMAX
X
testosterone cypionate
X X
ESTRADIOL, MENEST ESTRADIOL PATCH GENERIC ESTRADIOL PATCHES GENERIC ESTRADIOL PATCHES ESTRADIOL, MENEST VAGIFEM GENERIC ESTRADIOL PATCHES VAGIFEM GENERIC ESTRADIOL PATCHES
13.1.3 OB/GYN TOPICAL ANTIINFECTIVES
clindamycin phosphate metronidazole vandazole
X X X
CLEOCIN CLINDESSE 13.2 OVULATORY STIMULANTS
clomiphene citrate
X
13.3 ANDROGEN DRUGS
testosterone cypionate DEPO-TESTOSTERONE
X
13.4 ESTROGEN DRUGS
estradiol 1mg tab estradiol estrogen & methyltestosterone estrogen-methyltestosterone estropipate CENESTIN CLIMARA
X X X X X
DIVIGEL
X
ELESTRIN ENJUVIA ESTRACE
X X X
ESTRASORB ESTRING
X X
QLL
ESTROGEL
X 37
DRUG NAME
TIER LCG
EVAMIST FEMRING MENEST
SUGGESTED PREFFERED ALTERNATIVES
G
FB
NFB
PCL
GENERIC ESTRADIOL PATCHES ESTRADIOL, MENEST
X X
QLL X
MENOSTAR
X
MINIVELLE PREMARIN VAGIFEM
X X
GENERIC ESTRADIOL PATCHES GENERIC ESTRADIOL PATCHES
X
VIVELLE-DOT
GENERIC ESTRADIOL PATCHES
X
13.4.1 ESTROGEN/PROGESTIN COMBINATIONS
jinteli ACTIVELLA
X X
ANGELIQ
X
CLIMARA PRO
X
COMBIPATCH
X
FEMHRT
X
PREFEST PREMPHASE PREMPRO
X
estradiol/noreth acetate ee/noreth ac, PREMPHASE/PREMPRO estradiol patch + progesterone estradiol patch + progesterone ee/noreth ac, PREMPHASE/PREMPRO ee/noreth ac, PREMPHASE/PREMPRO
X X
13.4.3 SELECTIVE ESTROGEN RECEPTOR MODULATOR
EVISTA
X
13.5 PROGESTIN DRUGS
camila errin jolivette medroxyprogesterone acetate nora-be norethindrone norethindrone acetate
QLL QLL QLL QLL QLL QLL
X X X X X X X
CRINONE ENDOMETRIN PROMETRIUM
X
estradi/noreth ace, mdrxyprg
X
progesterone
X
13.7 CONTRACEPTIVES
altavera alyacen
QLL QLL
X X 38
DRUG NAME
TIER LCG
amethia amethyst apri aranelle aviane azurette balziva camrese/lo caziant cesia cryselle cyclafem dasetta elinest emoquette enpresse gianvi gildess/fe introvale jolessa junel/fe kariva kelnor 1-35 leena lessina levonorgestrel-eth estradiol levora-28 loryna low-ogestrel lutera microgestin/fe mono-linyah mononessa myzilra necon nortrel ocella ogestrel orsythia portia previfem quasense reclipsen
SUGGESTED PREFFERED ALTERNATIVES
QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL
G
FB
NFB
PCL
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 39
DRUG NAME
TIER LCG
solia sprintec sronyx syeda tilia fe tri-estarylla tri-legest fe tri-linyah trinessa tri-previfem tri-sprintec trivora-28 velivet viorele zarah zenchent zovia 1-35e zovia 1-50e BEYAZ FEMCON FE GENERESS FE LO LOESTRIN FE LO MINASTRIN FE LOSEASONIQUE MINASTRIN 24 FE NATAZIA NUVARING ORTHO EVRA ORTHO TRI-CYCLEN/LO QUARTETTE SAFYRAL SEASONIQUE YASMIN 28 YAZ
SUGGESTED PREFFERED ALTERNATIVES
G
QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL QLL
FB
NFB
PCL
X X X X X X X X X X X X X X X X X X X
QLL X QLL X QLL X QLL X QLL X QLL X QLL X QLL X QLL X QLL X QLL X QLL X QLL X QLL X QLL X CHAPTER 14: OPHTHALMIC MEDICATIONS
14.1.1 OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS
bacitracin bacitracin-polymyxin ciprofloxacin hcl erythromycin gentamicin sulfate neomycin-bacitracin-polymyxin
X X X X X X 40
generic oral contraceptives zenchent fe chewable, zeosa generic oral contraceptives generic oral contraceptives generic oral contraceptives amethia lo, camrese lo generic oral contraceptives generic oral contraceptives generic oral contraceptives aviane, lessina generic oral contraceptives generic oral contraceptives generic oral contraceptives amethia, camrese ocella,syeda,zarah gianvi, loryna, vestura
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
ofloxacin polymyxin b sul-trimethoprim sulfacetamide sodium AZASITE BESIVANCE MOXEZA VIGAMOX
G
FB
NFB
PCL
X X X X X
tobramycin, ciprofloxacin
X
ciprofl,levoflox,oflox,MOXEZA
X
ciproflox, levoflox, ofloxacin
X
trifluridine
X X X X X
azelastine hcl generic ophthalmic steroid generic ophthalmic steroid generic ophthalmic steroid generic ophthalmic steroid
X X X
tobramycindexamethasone tobra/dexame susp tobra/dexame susp
ciprofl,levoflox,oflox,MOXEZA
X
ZYMAXID 14.1.2 OPHTHALMIC TOPICAL ANTIVIRAL DRUGS
trifluridine ZIRGAN
X
14.2 OPHTHALMIC CORTICOSTEROID DRUGS
fluorometholone prednisolone acetate ALREX DUREZOL FML FORTE LOTEMAX VEXOL
X X
14.3 OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS
neomycin-polymyxin-dexameth neomycin-polymyxin-hc tobramycin-dexamethasone
X X X
TOBRADEX TOBRADEX ST ZYLET 14.5 ANTIGLAUCOMA DRUGS
acetazolamide brimonidine tartrate dorzolamide hcl dorzolamide-timolol latanoprost levobunolol hcl pilocarpine hcl timolol maleate travoprost ALPHAGAN P
X X X X X X X X X X
AZOPT
X
BETIMOL
X 41
brimonidine tartrate generics, ALPHAGAN P 0.1% generics, ALPHAGAN P 0.1%
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
FB
NFB
PCL
BETOPTIC S
X
COMBIGAN
X
COSOPT PF
X
ISTALOL LUMIGAN RESCULA
X X X
SIMBRINZA TIMOPTIC OCUDOSE TRAVATAN Z XALATAN ZIOPTAN
X X X X X
betaxolol generics, ALPHAGAN P 0.1% generics, ALPHAGAN P 0.1% generics, ALPHAGAN P 0.1% latanoprost latanoprost generics, ALPHAGAN P 0.1% timolol maleate multidose latanoprost latanoprost latanoprost
X X X X X X X X X X X
diclofenac, ketorolac azelastine hcl azelastine hcl azelastine hcl azelastine hcl diclofenac, ketorolac azelastine hcl diclofenac, ketorolac azelastine hcl azelastine hcl bromfenac
14.6 OTHER OPHTHALMIC DRUGS
atropine sulfate azelastine hcl cromolyn sodium diclofenac sodium epinastine hcl ACUVAIL ALOCRIL ALOMIDE BEPREVE EMADINE ILEVRO LASTACAFT NEVANAC PATADAY PATANOL PROLENSA RESTASIS
X X X X X
QLL
X CHAPTER 15: RESPIRATORY MEDICATIONS
15.1.1 BETA-2 ADRENERGIC DRUGS
albuterol 2, 4mg tab; 2mg/5mL syrup; 5mg/mL sol; 0.083% inhal sol albuterol metaproterenol sulfate ARCAPTA NEOHALER BROVANA FORADIL MAXAIR AUTOHALER
X X X X X
FORADIL PERFOROMIST
X
PROAIR HFA
X
42
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
G
PERFOROMIST PROAIR HFA PROVENTIL HFA SEREVENT DISKUS VENTOLIN HFA XOPENEX/CONCENTRATE XOPENEX HFA
FB
NFB
PCL
X X X X X X X
PROAIR HFA FORADIL PROAIR HFA levalbuterol PROAIR HFA
X X X X
DULERA, SYMBICORT DULERA, SYMBICORT PULMICORT FLEX, QVAR PULMICORT FLEX, QVAR
X
SYMBICORT
X X
PULMICORT FLEX, QVAR budesonide
X X
zafirlukast montelukast
15.1.2 METHYL XANTHINE DRUGS
theophylline theophylline anhydrous
X X
15.1.3 OTHER DRUGS FOR ASTHMA
budesonide cromolyn sodium epinephrine ipratropium bromide 0.02% soln ipratropium bromide ipratropium-albuterol ADVAIR DISKUS ADVAIR HFA ALVESCO ASMANEX ATROVENT HFA BREO ELLIPTA COMBIVENT/RESPIMAT DULERA EPIPEN/JR 2-PAK FLOVENT DISKUS/HFA PULMICORT PULMICORT FLEXHALER QVAR SPIRIVA SYMBICORT TUDORZA PRESSAIR
X X X X X X
X X X X
X X X X X
15.1.4 LEUKOTRIENE MODIFIERS
montelukast sodium zafirlukast ACCOLATE SINGULAIR
X X
15.2.1 ANTIHISTAMINES
arbinoxa cyproheptadine hcl levocetirizine dihydrochloride promethazine hcl 25mg tab
X X X X 43
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
promethazine hcl CLARINEX XYZAL
G
FB
NFB
PCL
X X X
desloratadine levocetirizine
X
15.2.3 ANTIHISTAMINE/DECONGESTANT COMBINATIONS
promethazine vc
X
15.3 ANTITUSSIVE AND EXPECTORANT DRUGS
benzonatate guaifenesin/codiene guaifenesin-codeine promethazine vc-codeine promethazine-codeine promethazine-dm REZIRA
X X X X X X
TUSSICAPS
X
TUSSIONEX
X
ZUTRIPRO
X
promethazine vc with cod hydrocodone/chlorphenira m susp hydrocodone/chlorphenira m susp promethazine vc with codeine
X
FORADIL, SPIRIVA
15.4 OTHER RESPIRATORY DRUGS
DALIRESP PULMOZYME
PA, SP X CHAPTER 16: UROLOGICAL MEDICATIONS
16.1.1 ANTICHOLINERGIC ANTISPASMODICS
oxybutynin chloride oxybutynin chloride er tolterodine tartrate trospium chloride DETROL DETROL LA ENABLEX GELNIQUE OXYTROL SANCTURA XR TOVIAZ VESICARE
X X X X X X X X X X X X
16.1.2 CHOLINERGIC STIMULANTS
bethanechol chloride
X
16.1.3 URINARY ANESTHETICS
phenazopyridine hcl
X
16.1.4 OTHER GENITOURINARY PRODUCTS
alfuzosin hcl finasteride
X X 44
tolterodine oxybutynin er, trospium er oxybutynin er, trospium er oxybutynin er, trospium er oxybutynin er, trospium er trospium er oxybutynin er, trospium er oxybutynin er, trospium er
DRUG NAME
TIER LCG
potassium citrate tamsulosin hcl AVODART ELMIRON FLOMAX JALYN MYRBETRIQ RAPAFLO UROXATRAL
SUGGESTED PREFFERED ALTERNATIVES
G
FB
NFB
PCL
X X X
finasteride
X X tamsulosin hcl X finasteride + tamsulosin X oxybutynin er, trospium er X alfuzosin er, tamsulosin X alfuzosin hcl CHAPTER 17: DIAGNOSTIC & MISCELLANEOUS MEDICATIONS
17.1 DIAGNOSTIC PRODUCTS
DEXCOM G4 MINILINK REAL-TIME TRANSMITTER PARADIGM REAL-TIME PRECISION XTRA SOF-SENSOR
X X X X X
FREESTYLE
FREESTYLE
17.2 MISCELLANEOUS DRUGS
THALOMID
PA, SP
X
17.3.1 APPETITE SUPPRESSANTS
phentermine hcl
X
QSYMIA
X
benzphet,diethylprop,phe nterm
17.3.2 OTHER WEIGHT LOSS PRODUCTS
BELVIQ
X phentermine CHAPTER 18: MEDICAL (MISCELLANEOUS) SUPPLIES
18.0 MEDICAL (MISCELLANEOUS) SUPPLIES
CONCEPTION MINIMED MINIMED RESERVOIR OPTICHAMBER PARADIGM PARADIGM INFUSION PARADIGM SILHOUETTE POLYFIN POLYFIN QR PRIMABELLA QUICK RELEASE SOFT TEFLON SILHOUETTE SOF-SET SOF-SET MICRO SURE-T
QLL
X X X X X X X X X X X X X X X
18.1 DIABETIC SUPPLIES
ACCU-CHEK
X 45
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
ACCU-CHEK ACTIVE ACCU-CHEK AVIVA ACCU-CHEK AVIVA PLUS ACCU-CHEK COMFORT CURVE ACCU-CHEK COMPACT ACCU-CHEK COMPACT BLUE CONTROL ACCU-CHEK FASTCLIX ACCU-CHEK NANO SMARTVIEW ACCU-CHEK SMARTVIEW ACCU-CHEK SOFTCLIX ASCENSIA AUTODISC AUTODISC NORMAL BREEZE 2 CLEVER CHOICE VOICE+ TST STRIP CONTOUR CONTOUR NEXT CONTOUR NEXT EZ CONTROL SOLUTION DEXCOM G4 FORA LANCING DEVICE FORA TEST STRIP FORA V30A FORACARE LANCETS FREESTYLE FREEDOM LITE FREESTYLE INSULINX TEST STRIPS FREESTYLE LANCETS FREESTYLE LITE STRIPS FREESTYLE TEST STRIPS GLUCOSE TEST STRIP NOVOFINE NOVOFINE 32 NOVOFINE AUTOCOVER ONE TOUCH DELICA ONE TOUCH LANCETS ONE TOUCH TEST STRIPS ONE TOUCH ULTRA 2 ONE TOUCH ULTRA SMART ONE TOUCH ULTRA SYSTEM ONE TOUCH ULTRA TEST STRIPS ONE TOUCH ULTRAMINI ONE TOUCH VERIO ONE TOUCH VERIO IQ
G
FB
NFB
PCL
X X X X X
FREESTYLE FREESTYLE FREESTYLE FREESTYLE FREESTYLE
X
FREESTYLE
X X
FREESTYLE FREESTYLE
X X X X X X X X X
FREESTYLE FREESTYLE FREESTYLE FREESTYLE FREESTYLE FREESTYLE FREESTYLE FREESTYLE FREESTYLE
X X
FREESTYLE FREESTYLE
X
FREESTYLE
X X X X X X X X
FREESTYLE FREESTYLE FREESTYLE FREESTYLE FREESTYLE FREESTYLE FREESTYLE FREESTYLE
X
X
X
X X X X X X X X X X X
46
DRUG NAME
SUGGESTED PREFFERED ALTERNATIVES
TIER LCG
PRECISION PRECISION XTRA PRODIGY PRODIGY INSULIN SYRINGE PRODIGY NO CODING PRODIGY PEN NEEDLE PRODIGY POCKET SOFT TOUCH SOFTCLIX SURE COMFORT LANCETS SURESTEP TRUEPLUS LANCETS TRUETEST TEST STRIPS TRUETRACK TEST STRIP ULTRA COMFORT VGO 20 VGO 30 VGO 40
G
FB
NFB
PCL
X X X
FREESTYLE FREESTYLE
X
FREESTYLE
X
FREESTYLE
X
FREESTYLE
X X
FREESTYLE FREESTYLE
X X X X X X
X X X X
KEY The symbol [ST] next to a drug name indicates that Step Therapy may apply to some or all strengths of the drug. The symbol [PA] next to a drug name indicates that prior authorization is required. The symbol [QLL] next to a drug name indicates a quantity level limit may apply to some or all of the strengths of the drug. The symbol [SP] next to a drug indicates that it is a specially medication. Certain benefits plans may have higher Copayments for these products. Refer to your Schedule of Benefits for further information. The symbol [LCG] next to a drug indicates that it is a low-cost generic. Certain benefit plans may have reduced Copayments for these products. Refer to your Schedule of Benefits for further information. The symbol [PCL] indicates that the drug is on the Preventive Care List. Certain benefit plans may have reduced Copayments for these products. Refer to your Schedule of Benefits for further information. Brand name drugs are listed in CAPITAL letters. Example: CELEBREX Generic drugs are listed in lower case letters. Example: ibuprofen
47
Alphabetic List Index abacavir ABILIFY/DISCMELT ABSTRAL ACANYA acarbose ACCOLATE ACCU-CHEK ACCU-CHEK ACTIVE ACCU-CHEK AVIVA ACCU-CHEK AVIVA PLUS ACCU-CHEK COMFORT CURVE ACCU-CHEK COMPACT ACCU-CHEK COMPACT BLUE CONTROL ACCU-CHEK FASTCLIX ACCU-CHEK NANO SMARTVIEW ACCU-CHEK SMARTVIEW ACCU-CHEK SOFTCLIX acebutolol hcl acetaminophen-codeine acetazolamide ACIPHEX ACTEMRA ACTIVELLA ACTONEL ACTOPLUS MET ACTOPLUS MET XR ACTOS ACUVAIL acyclovir adapalene ADCIRCA ADDERALL XR ADVAIR DISKUS ADVAIR HFA ADVICOR AGGRENOX albuterol sulfate alclometasone dipropionate alendronate sodium alfuzosin hcl allopurinol ALOCRIL ALOMIDE ALPHAGAN P alprazolam/er/xr ALREX ALTABAX altavera ALTOPREV ALVESCO alyacen amantadine
2.5.1 5.8 5.1.1.1 6.3 8.1.2 15.1.4 18.1 18.1 18.1 18.1 18.1 18.1
AMBIEN AMBIEN CR amethia amethyst amiloride hcl amiodarone hcl AMITIZA amitriptyline hcl amlodipine besylate amlodipine besylate-benazepril amlodipine-atorvastatin amox tr-potassium clavulanate amoxicillin amoxicillin-clavulanate er amphetamine salt combo AMPYRA AMRIX AMTURNIDE anagrelide hcl ANALPRAM ADVANCED ANALPRAM E ANALPRAM HC anastrozole ANGELIQ ANTARA antipyrine-benzocaine anucort-hc APIDRA/SOLOSTAR apri APRISO aranelle ARANESP arbinoxa ARCAPTA NEOHALER ARICEPT ARICEPT ODT ARIMIDEX ARIXTRA ARMOUR THYROID ASACOL HD ASCENSIA AUTODISC ASMANEX aspirin aspirin ec ASTELIN ASTEPRO ATACAND ATACAND HCT ATELVIA atenolol atenolol-chlorthalidone atorvastatin calcium atovaquone-proguanil hcl
18.1 18.1 18.1 18.1 18.1 4.4 5.1.1.2 14.5 9.4.2 10.2.6 13.4.1 8.6 8.1.3 8.1.3 8.1.3 14.6 2.5.2 6.3 4.6.2 5.9.1 15.1.3 15.1.3 4.8.2.1 12.4 15.1.1 6.1 8.6 16.1.4 11.2 14.6 14.6 14.5 5.2.1 14.2 2.2 13.7 4.8.2 15.1.3 13.7 2.5.2
48
5.2.2 5.2.2 13.7 13.7 4.3.3 4.7.3 9.7 5.5.1.1 4.2 4.5.6 4.8.2.1 2.1.5 2.1.5 2.1.5 5.9.1 5.9.4 11.3.2 4.5.6 3 9.6 9.6 9.6 3 13.4.1 4.8.1 7.1 9.6 8.1.1 13.7 9.6 13.7 10.2.2 15.2.1 15.1.1 5.9.3 5.9.3 3 12.3.2 8.4.1 9.6 18.1 15.1.3 11.1.1 11.1.1 7.2 7.2 4.5.4.2 4.5.4.2 8.6 4.4 4.5.6 4.8.2 2.7.3
ATRALIN ATRIPLA atropine sulfate atropine sulfate ATROVENT HFA AUTODISC NORMAL AVALIDE AVANDAMET AVANDARYL AVANDIA AVAPRO AVELOX/ABC PACK aviane AVINZA AVODART AVONEX AVONEX ADMINISTRATION PACK AVONEX PEN AXERT AZASITE azathioprine azelastine hcl azelastine hcl AZILECT azithromycin AZOPT AZOR azurette bacitracin bacitracin-polymyxin baclofen BACTROBAN balsalazide disodium balziva BARACLUDE BECONASE AQ BELVIQ benazepril hcl benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENZACLIN benzonatate benzoyl peroxide benztropine mesylate BEPREVE BESIVANCE betamethasone dipropionate betamethasone valerate BETASERON bethanechol chloride BETIMOL BETOPTIC S BEYAZ bicalutamide
6.3 2.5.1 14.6 5.9.2 15.1.3 18.1 4.5.4.2 8.1.3 8.1.3 8.1.3 4.5.4.2 2.1.9 13.7 5.1.1.1 16.1.4 10.2.3 10.2.3 10.2.3 5.1.2 14.1.1 3 7.2 14.6 5.7.2 2.1.4.1 14.5 4.5.6 13.7 14.1.1 14.1.1 11.3.1 2.2 9.6 13.7 2.5.2 7.2 17.3.2 4.5.4.1 4.5.6 4.5.4.2 4.5.4.2 6.3 15.3 6.3 5.7.1 14.6 14.1.1 6.1 6.1 10.2.3 16.1.2 14.5 14.5 13.7 3
BIDIL BIFERA RX BINOSTO bisoprolol fumarate bisoprolol-hydrochlorothiazide BONIVA BREEZE 2 BREO ELLIPTA BRILINTA brimonidine tartrate bromocriptine mesylate BROVANA budesonide budesonide ec bumetanide buprenorphine hcl buprenorphine hcl buprenorphine-naloxone bupropion hcl bupropion hcl sr bupropion hcl sr bupropion xl buspirone hcl butalbital compound-codeine butalbital-aspirin-caffeine butorphanol tartrate BUTRANS BYDUREON BYETTA BYSTOLIC CADUET calcipotriene calcitonin nasal spray calcitrene calcitriol calcium acetate calcium with vitamin d CAMBIA camila camrese/lo CANASA candesartan-hydrochlorothiazid captopril captopril-hydrochlorothiazide CARAC CARAFATE carbamazepine carbamazepine xr CARBATROL carbidopa-levodopa carbidopa-levodopa-entacapone CARDENE SR CARDIZEM LA CARDURA XL cartia xt
49
4.6.2 12.1.2 8.6 4.4 4.5.6 8.6 18.1 15.1.3 12.4 14.5 5.7.2 15.1.1 15.1.3 9.6 4.3.1 5.1.1.2 5.1.1.3 5.1.1.2 5.5.1.4 5.5.1.4 5.9.5 5.5.1.4 5.2.1 5.1.2 5.1.2 5.1.1 5.1.1.2 8.1.5.1 8.1.5.1 4.4 4.8.2.1 6.8 8.6 6.8 12.1.3 12.1.3 12.1.3 11.1.2 13.5 13.7 9.6 4.5.6 4.5.4.1 4.5.6 6.9.2 9.4.1 5.4.1 5.4.1 5.4.1 5.7.2 5.7.2 4.2 4.2 4.5.1 4.2
carvedilol caziant CEDAX cefaclor/er cefadroxil cefdinir cefpodoxime proxetil cefprozil CEFTIN cefuroxime CELEBREX CELLCEPT CENESTIN cephalexin CEREFOLIN CEREFOLIN NAC cesia CETRAXAL cevimeline hcl CHANTIX chlordiazepoxide hcl chlordiazepoxide-clidinium chlorpromazine hcl chlorthalidone chlorzoxazone cholestyramine choline mag trisalicylate ciclopirox cilostazol cimetidine CIMZIA CIPRO HC CIPRODEX ciprofloxacin er ciprofloxacin hcl ciprofloxacin hcl citalopram citalopram hbr CLARINEX clarithromycin/er CLEOCIN CLEVER CHOICE VOICE+ TST STRIP CLIMARA CLIMARA PRO clindamycin hcl clindamycin phosphate clindamycin phosphate clindamycin phosphate clindamycin-benzoyl peroxide CLINDESSE clobetasol emollient clobetasol propionate CLOBEX CLODERM clomiphene citrate
4.4 13.7 2.1.1 2.1.1 2.1.1 2.1.1 2.1.1 2.1.1 2.1.1 2.1.1 11.1.2 3 13.4 2.1.1 12.1.2 12.8 13.7 7.1 7.3 5.9.5 5.2.1 9.3 5.8.1 4.3.2 11.3.2 4.8.1 11.1.1 2.4.2 12.4 9.4 3 7.1 7.1 2.1.9 14.1.1 2.1.9 5.5.1.3 5.5.1.3 15.2.1 2.1.4.1 13.1.3 18.1 13.4 13.4.1 2.1.3 6.3 13.1.3 2.1.3 6.3 13.1.3 6.1 6.1 6.1 6.1 13.2
clomipramine hcl clonazepam clonidine clonidine hcl clopidogrel clorazepate dipotassium clotrimazole clotrimazole clotrimazole-betamethasone clozapine COLCRYS colestipol hcl COLYTE WITH FLAVOR PACKS COMBIGAN COMBIPATCH COMBIVENT COMBIVENT RESPIMAT COMBIVIR COMPLERA COMTAN CONCEPTION CONCERTA CONDYLOX CONTOUR CONTOUR NEXT CONTOUR NEXT EZ CONTROL SOLUTION COPAXONE CORDRAN COREG CR COSOPT PF COUMADIN COZAAR CREON CRESTOR CRINONE cromolyn sodium cromolyn sodium cryselle cyclafem cyclobenzaprine hcl cyclosporine modified CYMBALTA cyproheptadine hcl CYTOMEL DALIRESP DAPSONE dasetta DAYTRANA DELZICOL DENAVIR DEPAKOTE ER DEPLIN DEPO-TESTOSTERONE desipramine hcl
50
5.5.1.1 5.4.2 4.5.2 4.5.2 12.4 5.2.1 2.4.1 2.4.2 2.4.3 5.8 11.2 4.8.1 9.6 14.5 13.4.1 15.1.3 15.1.3 2.5.1 2.5.1 5.7.2 18 5.9.1 6.7 18.1 18.1 18.1 18.1 10.2.3 6.1 4.4 14.5 12.3.1 4.5.4.2 9.6 4.8.2 13.5 14.6 15.1.3 13.7 13.7 11.3.2 3 5.5.1.4 15.2.1 8.4.1 15.4 2.7.4 13.7 5.9.1 9.6 2.5.2 5.4.4 12.1.3 13.3 5.5.1.2
desmopressin acetate desonide desoximetasone DETROL DETROL LA dexamethasone dexamethasone sodium phosphate DEXCOM G4 DEXCOM G4 DEXILANT dexmethylphenidate hcl dextroamphetamine sulfate dextroamphetamine-amphetamine diazepam diazepam diclofenac potassium diclofenac sodium diclofenac sodium dicloxacillin sodium dicyclomine hcl DIFFERIN DIFICID diflunisal digoxin DILANTIN diltiazem/er DIOVAN DIOVAN HCT DIPENTUM diphenoxylate-atropine dipyridamole divalproex sodium/er DIVIGEL donepezil hcl DORYX dorzolamide hcl dorzolamide-timolol DOVONEX doxazosin mesylate doxepin hcl doxycycline hyclate doxycycline hyclate doxycycline monohydrate dronabinol DUAC DUETACT DUEXIS DULERA duloxetine DUREZOL DYMISTA econazole nitrate EDARBI EDARBYCLOR EDLUAR
8.6 6.1 6.1 16.1.1 16.1.1 8.3.1 8.3.1 17.1 18.1 9.4.2 5.9.1 5.9.1 5.9.1 5.2.1 5.4.2 11.1.2 14.6 11.1.2 2.1.5 9.3 6.3 2.8 11.1.1 4.1 5.4.3 4.2 4.5.4.2 4.5.4.2 9.6 9.2 12.4 5.4.4 13.4 5.9.3 2.1.7 14.5 14.5 6.8 4.5.1 5.5.1.1 7.3 2.1.7 2.1.7 5.6 6.3 8.1.3 11.1.2 15.1.3 5.5.1.4 14.2 7.2 2.4.2 4.5.4.2 4.5.6 5.2.2
EFFEXOR XR EFFIENT ELESTRIN ELIDEL ELIGARD elinest eliphos ELIQUIS ELMIRON EMADINE EMEND emoquette ENABLEX enalapril maleate enalapril-hydrochlorothiazide ENBREL endocet ENDOMETRIN ENJUVIA enoxaparin sodium enpresse entacapone enulose EPICERAM EPIDUO epinastine hcl epinephrine EPIPEN 2-PAK EPIPEN JR 2-PAK EPIVIR EPIVIR HBV eplerenone eprosartan mesylate EPZICOM errin ERTACZO ERY-TAB erythromycin erythromycin erythromycin erythromycin-benzoyl peroxide escitalopram oxalate ESOMEPRAZOLE STRONTIUM estazolam ESTRACE estradiol ESTRASORB ESTRING ESTROGEL estrogen & methyltestosterone estrogen-methyltestosterone estropipate etidronate disodium etodolac EURAX
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5.5.1.4 12.4 13.4 6.9.2 3 13.7 12.1.3 12.3.3 16.1.4 14.6 5.6 13.7 16.1.1 4.5.4.1 4.5.6 3 5.1.1.1 13.5 13.4 12.3.2 13.7 5.7.2 12.7 6.9.2 6.3 14.6 15.1.3 15.1.3 15.1.3 2.5.1 2.5.2 4.3.3 4.5.4.2 2.5.1 13.5 2.4.2 2.1.4 6.3 14.1.1 2.1.4 6.3 5.5.1.3 9.4.2 5.2.2 13.4 13.4 13.4 13.4 13.4 13.4 13.4 13.4 8.6 11.1.2 6.9.3
EVAMIST EVISTA EXALGO EXELDERM EXELON exemestane EXFORGE/HCT EXTAVIA FACTIVE famciclovir famotidine FANAPT felbamate felodipine er FEMARA FEMCON FE FEMHRT FEMRING fenofibrate fenofibric acid FENOGLIDE fentanyl FENTORA FINACEA finasteride flecainide acetate FLECTOR FLOMAX FLOVENT DISKUS FLOVENT HFA fluconazole fludrocortisone acetate flunisolide fluocinolone acetonide fluocinonide fluorometholone FLUOROPLEX fluorouracil fluoxetine hcl fluphenazine hcl flurazepam hcl flurbiprofen fluticasone propionate fluticasone propionate fluvastatin sodium fluvoxamine maleate FML FORTE FOCALIN XR folic acid FOLTX fondaparinux sodium FORA LANCING DEVICE FORA TEST STRIP FORA V30A FORACARE LANCETS
13.4 13.4.3 5.1.1.1 2.4.2 5.9.3 3 4.5.6 10.2.3 2.1.9 2.5.2 9.4 5.8 5.4.7 4.2 3 13.7 13.4.1 13.4 4.8.1 4.8.1 4.8.1 5.1.1.1 5.1.1.1 6.3 16.1.4 4.7.1.3 6.9.5 16.1.4 15.1.3 15.1.3 2.3 8.3.2 7.2 6.1 6.1 14.2 6.9.2 6.9.2 5.5.1.3 5.8 5.2.2 11.1.2 6.1 7.2 4.8.2 5.5.1.3 14.2 5.9.1 12.1.3 12.8 12.3.2 18.1 18.1 18.1 18.1
FORADIL FORTAMET FORTEO FOSAMAX PLUS D fosinopril sodium fosinopril-hydrochlorothiazide FOSRENOL FRAGMIN FREESTYLE FREEDOM LITE FREESTYLE INSULINX TEST STRIPS FREESTYLE LANCETS FREESTYLE LITE STRIPS FREESTYLE TEST STRIPS FROVA furosemide gabapentin galantamine hbr GELNIQUE gemfibrozil GENERESS FE GENOTROPIN gentamicin sulfate gentamicin sulfate gentamicin sulfate GEODON gianvi gildess/fe GILENYA GLEEVEC glimepiride glipizide/er glipizide-metformin GLUCAGEN GLUCAGEN GLUCAGON EMERGENCY KIT GLUCOSE TEST STRIP GLUMETZA glyburide glyburide micronized glyburide-metformin hcl GOLYTELY GRALISE granisetron hcl GRIFULVIN V griseofulvin guaifenesin/codiene guaifenesin-codeine guanfacine hcl HALFLYTELY-BISACODYL halobetasol propionate HALOG haloperidol HECTOROL HELIDAC heparin sodium
52
15.1.1 8.1.2 8.6 8.6 4.5.4.1 4.5.6 12.7 12.3.2 18.1 18.1 18.1 18.1 18.1 5.1.2 4.3.1 5.4.7 5.9.3 16.1.1 4.8.1 13.7 10.2.4 2.2 14.1.1 2.8.2 5.8 13.7 13.7 5.9.4 3 8.1.2 8.1.2 8.1.2 8.2 8.1.6 8.2 18.1 8.1.2 8.1.2 8.1.2 8.1.2 9.6 5.4.7 5.6 2.3 2.3 15.3 15.3 4.5.2 9.6 6.1 6.1 5.8 12.1.3 9.4.3 12.3.2
HORIZANT HUMALOG products HUMATROPE HUMIRA HUMULIN products hydrochlorothiazide hydrocodone bit-ibuprofen hydrocodone-acetaminophen hydrocortisone hydrocortisone hydrocortisone hydrocortisone acetate hydrocortisone butyrate hydrocortisone valerate hydromorphone hcl hydroxychloroquine sulfate hydroxyurea hydroxyzine hyoscyamine sulfate HYZAAR ibandronate sodium ibuprofen ILEVRO imipramine hcl imiquimod IMITREX INCIVEK indapamide indomethacin INTELENCE INTERMEZZO introvale INTUNIV INVEGA ipratropium bromide ipratropium bromide ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide ISENTRESS isoniazid isosorbide isosorbide dinitrate isotretinoin ISTALOL itraconazole JALYN JANUMET/XR JANUVIA JENTADUETO jinteli jolessa jolivette junel/fe KADIAN
5.4.7 8.1.1 10.2.4 3 8.1.1 4.3.2 5.1.1.2 5.1.1.2 6.1 9.6 8.3.1 9.6 6.1 6.1 5.1.1.1 2.7.3 3 6.2 9.3 4.5.4.2 8.6 11.1.2 14.6 5.5.1.1 6.9.2 5.1.2 2.5.1 4.3.2 11.1.2 2.5.1 5.2.2 13.7 5.9.6 5.8 7.2 15.1.3 15.1.3 4.5.4.2 4.5.6 2.5.1 2.7.2 4.6.1 4.6.1 6.3.1 14.5 2.3 16.1.4 8.1.5.2 8.1.5.2 8.1.5.2 13.4.1 13.7 13.5 13.7 5.1.1.1
KALETRA KAPVAY kariva KAZANO kelnor 1-35 KENALOG KEPPRA KEPPRA XR ketoconazole ketoconazole ketoprofen ketorolac tromethamine KINERET KOMBIGLYZE XR KRISTALOSE labetalol hcl lactulose LAMICTAL/ODT/XR lamivudine lamivudine-zidovudine lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR LASTACAFT latanoprost LATUDA LAZANDA leena leflunomide LESCOL LESCOL XL lessina LETAIRIS letrozole leucovorin calcium LEVAQUIN LEVEMIR/FLEXPEN levetiracetam levobunolol hcl levocarnitine levocetirizine dihydrochloride levofloxacin levonorgestrel-eth estradiol levonorg-eth estrad eth estrad levora-28 levothyroxine sodium LEXAPRO LEXIVA LIALDA lidocaine hcl lidocaine-prilocaine LIDODERM LINZESS
53
2.5.1 5.9.6 13.7 8.1.5.2 13.7 6.1 5.4.7 5.4.7 2.3 2.4.2 11.1.2 11.1.2 10.2.6 8.1.5.2 12.7 4.4 12.7 5.4.7 2.5.1 2.5.1 5.4.7 4.1 9.4.2 8.1.1 8.1.1 14.6 14.5 5.8 5.1.1.1 13.7 3 4.8.2 4.8.2 13.7 4.6.3 3 3 2.1.9 8.1.1 5.4.7 14.5 12.1.3 15.2.1 2.1.9 13.7 13.7 13.7 8.4.1 5.5.1.3 2.5.1 9.6 1.2 1.2 1.2 9.7
liothyronine LIPITOR LIPOFEN LIPTRUZET lisinopril lisinopril-hydrochlorothiazide lithium carbonate LIVALO LO LOESTRIN FE LO MINASTRIN FE LOCOID/LIPOCREAM lorazepam loryna losartan potassium losartan-hydrochlorothiazide LOSEASONIQUE LOTEMAX LOTREL lovastatin LOVAZA LOVENOX low-ogestrel ludent fluoride LUMIGAN LUNESTA lutera LUVOX CR LYRICA LYSTEDA MALARONE malathion MAXAIR AUTOHALER MAXALT MAXALT MLT meclizine hcl medroxyprogesterone acetate mefloquine hcl MEGACE ES megestrol acetate meloxicam MENEST MENOSTAR mercaptopurine METADATE CD metaproterenol sulfate metaxalone metformin hcl metformin hcl er methadone hcl methimazole methocarbamol methotrexate methyldopa methylin methylin er
8.4.1 4.8.2 4.8.1 4.8.2.1 4.5.4.1 4.5.6 5.3 4.8.2 13.7 13.7 6.1 5.2.1 13.7 4.5.4.2 4.5.6 13.7 14.2 4.5.6 4.8.2 4.8.1 12.3.2 13.7 12.1.4 14.5 5.2.2 13.7 5.5.1.3 5.4.7 12.5 2.7.3 6.9.3 15.1.1 5.1.2 5.1.2 5.6 13.5 2.7.3 3 3 11.1.2 13.4 13.4 3 5.9.1 15.1.1 11.3.2 8.1.2 8.1.2 5.1.1.1 8.4.2 11.3.2 3 4.5.2 5.9.1 5.9.1
methylphenidate er methylphenidate er-la methylphenidate hcl methylphenidate hcl cd methylphenidate sr methylprednisolone metoclopramide hcl metolazone metoprolol succinate metoprolol tartrate metoprolol-hydrochlorothiazide METROGEL metronidazole metronidazole metronidazole MICARDIS MICARDIS HCT microgestin/fe MIGRANAL MINASTRIN 24 FE MINILINK REAL-TIME TRANSMITTER MINIMED MINIMED RESERVOIR MINIVELLE minocycline hcl minoxidil MIRAPEX MIRAPEX ER mirtazapine misoprostol modafinil moexipril hcl moexipril-hydrochlorothiazide mometasone furoate mono-linyah mononessa montelukast sodium morphine sulfate/er MOVIPREP MOXEZA MULTAQ mupirocin mycophenolate mofetil MYFORTIC MYRBETRIQ myzilra nabumetone nadolol NAFTIN naltrexone hcl NAMENDA NAMENDA XR NAPRELAN naproxen naproxen sodium
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5.9.1 5.9.1 5.9.1 5.9.1 5.9.1 8.3.1 9.3 4.3.2 4.4 4.4 4.5.6 6.3 6.3 13.1.3 2.7.5 4.5.4.2 4.5.4.2 13.7 5.1.2 13.7 17.1 18 18 13.4 2.1.7 4.5.1 5.7.2 5.7.2 5.5.1.4 9.4.1 5.9.1 4.5.4.1 4.5.6 6.1 13.7 13.7 15.1.4 5.1.1.1 9.6 14.1.1 4.7.5 2.2 3 3 16.1.4 13.7 11.1.2 4.4 2.4.2 5.9.2 5.9.3 5.9.3 11.1.2 11.1.2 11.1.2
naratriptan hcl NASACORT AQ NASCOBAL NASONEX NATAZIA nateglinide necon neomycin-bacitracin-polymyxin neomycin-polymyxin-dexameth neomycin-polymyxin-hc neomycin-polymyxin-hc neomycin-polymyxin-hydrocort NEORAL NESINA NEUPRO NEVANAC nevirapine NEXIUM NIASPAN nicotine nifediac cc nifedical xl nifedipine er nisoldipine nitrofurantoin nitrofurantoin mono-macro nitroglycerin nitroglycerin patch NITROSTAT nizatidine nora-be NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX norethindrone norethindrone acetate NOROXIN nortrel nortriptyline hcl NORVIR NOVOFINE NOVOFINE 32 NOVOFINE AUTOCOVER NOVOLIN products NOVOLOG products NUCYNTA NUCYNTA ER NUEDEXTA NULYTELY WITH FLAVOR PACKS NUTROPIN/AQ/AQ NUSPIN NUVARING NUVIGIL nystatin nystatin nystatin-triamcinolone ocella
5.1.2 7.2 12.1.3 7.2 13.7 8.1.2 13.7 14.1.1 14.3 7.1 14.3 7.1 3 8.1.5.2 5.7.2 14.6 2.5.1 9.4.2 4.8.1 5.9.5 4.2 4.2 4.2 4.2 2.1.8 2.1.8 4.6.1 4.6.1 4.6.1 9.4 13.5 10.2.4 10.2.4 13.5 13.5 2.1.9 13.7 5.5.1.2 2.5.1 18.1 18.1 18.1 8.1.1 8.1.1 5.1.1.1 5.1.1.1 5.9.2 9.6 10.2.4 13.7 5.9.1 2.3 2.4.2 2.4.3 13.7
ofloxacin ofloxacin ofloxacin ogestrel olanzapine olanzapine odt olanzapine-fluoxetine hcl OLUX/-E OMECLAMOX-PAK omeprazole omeprazole-sodium bicarbonate OMNARIS OMNITROPE ondansetron hcl ondansetron odt ONE TOUCH DELICA ONE TOUCH LANCETS ONE TOUCH TEST STRIPS ONE TOUCH ULTRA 2 ONE TOUCH ULTRA SMART ONE TOUCH ULTRA SYSTEM ONE TOUCH ULTRA TEST STRIPS ONE TOUCH ULTRAMINI ONE TOUCH VERIO ONE TOUCH VERIO IQ ONFI ONGLYZA ONMEL ONSOLIS OPANA OPANA ER OPTICHAMBER ORACEA ORAVIG ORENCIA orphenadrine citrate orsythia ORTHO EVRA ORTHO TRI-CYCLEN/LO OSENI OSMOPREP oxaprozin oxazepam oxcarbazepine OXISTAT oxybutynin chloride oxybutynin chloride er oxycodone hcl oxycodone-acetaminophen OXYCONTIN oxymorphone hcl OXYTROL PANCREAZE pancrelipase 5,000 pantoprazole sodium
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7.1 14.1.1 2.1.9 13.7 5.8 5.8 5.8.1.1 6.1 9.4.3 9.4.2 9.4.2 7.2 10.2.4 5.6 5.6 18.1 18.1 18.1 18.1 18.1 18.1 18.1 18.1 18.1 18.1 5.4.2 8.1.5.2 2.3 5.1.1.1 5.1.1.1 5.1.1.1 18 2.1.7 2.3 3 11.3.2 13.7 13.7 13.7 8.1.5.2 9.5 11.1.2 5.2.1 5.4.1 2.4.2 16.1.1 16.1.1 5.1.1.1 5.1.1.1 5.1.1.1 5.1.1.1 16.1.1 9.6 9.6 9.4.2
PARADIGM PARADIGM INFUSION PARADIGM REAL-TIME PARADIGM SILHOUETTE paroxetine hcl PATADAY PATANASE PATANOL peg 3350-electrolyte PEGASYS PEGASYS PROCLICK PEGINTRON/REDIPEN penicillin v potassium PENNSAID PENTASA pentoxifylline PERFOROMIST permethrin 5% perphenazine PERTZYE phenazopyridine hcl phenobarbital phentermine hcl PHENYTEK phenytoin sodium extended PHOSLYRA PICATO pilocarpine hcl pilocarpine hcl pindolol pioglitazone hcl pioglitazone-metformin piroxicam PLAVIX podofilox POLYFIN POLYFIN QR polymyxin b sul-trimethoprim portia potassium chloride potassium citrate POTIGA PRADAXA pramipexole dihydrochloride PRAMOSONE/E PRANDIMET PRANDIN pravastatin sodium prazosin hcl PRECISION PRECISION XTRA PRECISION XTRA prednisolone prednisolone acetate prednisolone sodium phosphate
18 18 17.1 18 5.5.1.3 14.6 7.2 14.6 9.6 10.2.3 10.2.3 10.2.3 2.1.5 6.9.5 9.6 4.9 15.1.1 6.9.3 5.8 9.6 16.1.3 5.4.6 17.3.1 5.4.3 5.4.3 12.1.3 6.9.2 7.3 14.5 4.4 8.1.3 8.1.3 11.1.2 12.4 6.7 18 18 14.1.1 13.7 12.2 16.1.4 5.4.7 12.3.5 5.7.2 6.1 8.1.2 8.1.2 4.8.2 4.5.1 18.1 17.1 18.1 8.3.1 14.2 8.3.1
prednisone PREFERA OB PREFERA-OB ONE PREFERA-OB PLUS DHA PREFEST PREMARIN PREMPHASE PREMPRO PRENATE DHA PRENATE ELITE PRENATE ESSENTIAL PREPOPIK PREVACID PREVIDENT previfem PREVPAC PREZISTA PRIMABELLA primidone PRISTIQ ER PROAIR HFA probenecid prochlorperazine maleate PROCRIT proctosol-hc proctozone-hc PRODIGY PRODIGY INSULIN SYRINGE PRODIGY NO CODING PRODIGY PEN NEEDLE PRODIGY POCKET PROGRAF PROLENSA promethazine hcl promethazine hcl promethazine vc promethazine vc-codeine promethazine-codeine promethazine-dm promethegan PROMETRIUM PROMISEB propafenone hcl propranolol hcl propylthiouracil PROTONIX PROTOPIC PROVENTIL HFA PROVIGIL PULMICORT PULMICORT FLEXHALER PULMOZYME PYLERA pyridostigmine bromide QNASL
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8.3.1 13.1.1 13.1.1 13.1.1 13.4.1 13.4 13.4.1 13.4.1 13.1.1 13.1.1 13.1.1 9.6 9.4.2 12.1.4 13.7 9.4.3 2.5.1 18 5.4.6 5.5.1.4 15.1.1 11.2 5.6 10.2.2 9.6 9.6 18.1 18.1 18.1 18.1 18.1 3 14.6 5.6 15.2.1 15.2.3 15.3 15.3 15.3 5.6 13.5 6.9.2 4.7.1.3 4.4 8.4.2 9.4.2 6.9.2 15.1.1 5.9.1 15.1.3 15.1.3 15.4 9.4.3 5.9.2 7.2
QSYMIA QUALAQUIN QUARTETTE quasense quetiapine fumarate QUICK RELEASE SOFT TEFLON QUILLIVANT XR quinapril hcl quinapril-hydrochlorothiazide QVAR rabeprazole ramipril RANEXA ranitidine hcl RAPAFLO RAPAMUNE RAYOS REBIF REBIF REBIDOSE reclipsen RECTIV RELENZA RELISTOR RELPAX RENAGEL RENVELA reprexain REQUIP XL RESCULA RESTASIS RETIN-A MICRO/PUMP REVATIO REVLIMID REYATAZ REZIRA RHINOCORT AQUA ribapak ribavirin rifampin RIOMET RISPERDAL CONSTA risperidone RITALIN LA rivastigmine rizatriptan ropinirole hcl roxicet ROXICET ROZEREM RYTHMOL SR SAFYRAL SAIZEN salsalate SANCTURA XR SANCUSO
17.3.1 2.7.3 13.7 13.7 5.8 18 5.9.1 4.5.4.1 4.5.6 15.1.3 9.4.2 4.5.4.1 4.9 9.4 16.1.4 3 8.3.1 10.2.3 10.2.3 13.7 9.6 2.5.2 9.6 5.1.2 12.7 12.7 5.1.1.2 5.7.2 14.5 14.6 6.3 4.6.2 3 2.5.1 15.3 7.2 2.5.2 2.5.2 2.7.2 8.1.2 5.8 5.8 5.9.1 5.9.3 5.1.2 5.7.2 5.1.1.1 5.1.1.1 5.2.2 4.7.1.3 13.7 10.2.4 11.1.1 16.1.1 5.6
SANDOSTATIN LAR SANTYL SAPHRIS SAVELLA SEASONIQUE selenium sulfide SENSIPAR SEREVENT DISKUS SEROQUEL SEROQUEL XR sertraline hcl SFROWASA sildenafil SILENOR SILHOUETTE silver sulfadiazine SIMBRINZA SIMCOR SIMPONI simvastatin SINGULAIR SKELAXIN sodium fluoride sodium sulfacetamide-sulfur SOF-SENSOR SOF-SET SOF-SET MICRO SOFT TOUCH SOFTCLIX SOLARAZE solia SOLODYN SOMA SOMATULINE DEPOT SORILUX sotalol SPIRIVA spironolactone spironolactone-hctz sprintec SPRIX sronyx STALEVO STELARA STRATTERA STRIBILD SUBOXONE SUBSYS SUCLEAR sucralfate SULAR sulfacetamide sodium sulfacetamide sodium sulfamethoxazole-trimethoprim sulfasalazine
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3 6.9.2 5.8 5.5.1.4 13.7 6.8 8.6 15.1.1 5.8 5.8 5.5.1.3 9.6 4.6.2 5.2.2 18 2.2 14.5 4.8.2.1 3 4.8.2 15.1.4 11.3.2 12.1.4 6.3 17.1 18 18 18.1 18.1 6.9.2 13.7 2.1.7 11.3.2 3 6.8 4.7.5 15.1.3 4.3.3 4.3.3 13.7 11.1.2 13.7 5.7.2 3 5.9.6 2.5.1 5.1.1.2 5.1.1.1 9.6 9.4.1 4.2 6.8 14.1.1 2.1.6 9.6
sulfasalazine dr sulindac sumatriptan SUMAVEL DOSEPRO SUPRAX SUPREP SURE COMFORT SURE COMFORT LANCETS SURESTEP SURE-T SUSTIVA syeda SYMBICORT SYMBYAX SYMLINPEN 120 SYMLINPEN 60 SYNTHROID TACLONEX tacrolimus TAMIFLU tamoxifen citrate tamsulosin hcl TARKA TAZORAC TEGRETOL XR TEKAMLO TEKTURNA TEKTURNA HCT temazepam TEMODAR terazosin hcl terbinafine hcl terconazole TESTIM testosterone cypionate tetracycline hcl TEVETEN TEVETEN HCT TEV-TROPIN THALOMID theophylline theophylline anhydrous thioridazine hcl thiothixene TIKOSYN tilia fe timolol maleate timolol maleate TIMOPTIC OCUDOSE tinidazole tizanidine hcl TOBI TOBRADEX TOBRADEX ST tobramycin sulfate
9.6 11.1.2 5.1.2 5.1.2 2.1.1 9.6 18.1 18.1 18.1 18 2.5.1 13.7 15.1.3 5.8.1.1 8.1.4 8.1.4 8.4.1 6.8 3 2.5.2 3 16.1.4 4.5.6 6.8 5.4.1 4.5.6 4.5.6 4.5.6 5.2.2 3 4.5.1 2.3 2.4.1 13.3 13.3 2.1.7 4.5.4.2 4.5.4.2 10.2.4 17.2 15.1.2 15.1.2 5.8 5.8 4.7.5 13.7 4.4 14.5 14.5 2.7.5 11.3.1 2.8.2 14.3 14.3 2.8.2
tobramycin-dexamethasone tolterodine tartrate TOPAMAX topiramate TOPROL XL torsemide TOVIAZ TRACLEER TRADJENTA tramadol hcl/er tramadol hcl-acetaminophen trandolapril TRANSDERM-SCOP tranylcypromine sulfate TRAVATAN Z travoprost trazodone hcl tretinoin tretinoin tretinoin tretinoin microsphere TREXIMET triamcinolone acetonide triamcinolone acetonide triamcinolone acetonide triamterene-hctz triazolam TRIBENZOR TRICOR tri-estarylla trifluoperazine hcl trifluridine TRIGLIDE trihexyphenidyl hcl tri-legest fe tri-linyah TRILIPIX trilyte with flavor packets trimethoprim trinessa tri-previfem tri-sprintec trivora-28 trospium chloride TRUEPLUS LANCETS TRUETEST TEST STRIPS TRUETRACK TEST STRIP TRUVADA TUDORZA PRESSAIR TUSSICAPS TUSSIONEX TWYNSTA TYKERB ULESFIA ULORIC
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14.3 16.1.1 5.4.7 5.4.7 4.4 4.3.1 16.1.1 4.6.3 8.1.5.2 5.1.1 5.1.1 4.5.4.1 5.6 5.5.2 14.5 14.5 5.5.1.4 3 6.3 6.9.2 6.3 5.1.2 6.1 7.2 7.3 4.3.3 5.2.2 4.5.6 4.8.1 13.7 5.8 14.1.2 4.8.1 5.7.1 13.7 13.7 4.8.1 9.6 2.1.8 13.7 13.7 13.7 13.7 16.1.1 18.1 18.1 18.1 2.5.1 15.1.3 15.3 15.3 4.5.6 3 6.9.3 11.2
ULTRA COMFORT ULTRAVATE PAC ULTRESA UROXATRAL ursodiol VAGIFEM valacyclovir VALCYTE valproic acid valsartan-hydrochlorothiazide VALTREX VANCOCIN HCL vancomycin hcl vandazole VASCEPA VECTICAL velivet VELTIN venlafaxine hcl venlafaxine hcl er VENLAFAXINE HCL ER VENTOLIN HFA VERAMYST verapamil verapamil/er pm VEREGEN veripred 20 VESICARE VEXOL VGO 20 VGO 30 VGO 40 VICTOZA 2-PAK VICTOZA 3-PAK VICTRELIS VIGAMOX VIIBRYD VIMOVO VIMPAT viorele VIRAMUNE VIRAMUNE XR VIREAD vitamin d VIVELLE-DOT VOLTAREN voriconazole VYTORIN VYVANSE warfarin sodium WELCHOL WELLBUTRIN XL westhroid XALATAN XARELTO
18.1 6.1 9.6 16.1.4 9.6 13.4 2.5.2 2.5.2 5.4.4 4.5.6 2.5.2 2.8 2.8 13.1.3 4.8.1 6.8 13.7 6.3 5.5.1.4 5.5.1.4 5.5.1.4 15.1.1 7.2 4.2 4.2 6.9.2 8.3.1 16.1.1 14.2 18.1 18.1 18.1 8.1.5.1 8.1.5.1 2.5.1 14.1.1 5.5.1.3 11.1.2 5.4.7 13.7 2.5.1 2.5.1 2.5.1 12.1.3 13.4 6.9.5 2.3 4.8.2.1 5.9.1 12.3.1 4.8.1 5.5.1.4 8.4.1 14.5 12.3.3
XELJANZ XELODA XERESE XIFAXAN XOLAIR XOPENEX XOPENEX CONCENTRATE XOPENEX HFA XYZAL YASMIN 28 YAZ zafirlukast zaleplon zamicet zarah ZEGERID ZEMPLAR zenchent ZENPEP ZETIA ZETONNA ZIAGEN ZIANA ZIOPTAN ziprasidone hcl ZIRGAN zoledronic acid zolmitriptan zolpidem tartrate/er ZOLPIMIST ZOMIG ZOMIG ZMT zonisamide ZOSTAVAX zovia 1-35e zovia 1-50e ZOVIRAX ZUBSOLV ZUPLENZ ZUTRIPRO ZYCLARA ZYLET ZYMAXID ZYPREXA ZYPREXA ZYDIS ZYTIGA ZYVOX
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3 3 2.6 2.8 10.2.7 15.1.1 15.1.1 15.1.1 15.2.1 13.7 13.7 15.1.4 5.2.2 5.1.1.2 13.7 9.4.2 12.1.3 13.7 9.6 4.8.1 7.2 2.5.1 6.3 14.5 5.8 14.1.2 8.6 5.1.2 5.2.2 5.2.2 5.1.2 5.1.2 5.4.7 10 13.7 13.7 2.6 5.1.1.2 5.6 15.3 6.9.2 14.3 14.1.1 5.8 5.8 3 2.8
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