Arkansas Blue Cross and Blue Shield Value Formulary (1/1/2016) INTRODUCTION....................................................................................................................................................................................................... 4 PREFACE ................................................................................................................................................................................................................. 4 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE ...................................................................................................................................... 5 DRUG LIST PRODUCT DESCRIPTIONS ................................................................................................................................................................ 5 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 5 LEGEND ................................................................................................................................................................................................................... 6 ANALGESICS........................................................................................................................................................................................................... 7 NSAIDs ........................................................................................................................................................................................................... 7 NSAIDs, COMBINATIONS ............................................................................................................................................................................. 7 NSAIDs, TOPICAL ......................................................................................................................................................................................... 7 COX-2 INHIBITORS ....................................................................................................................................................................................... 7 GOUT ............................................................................................................................................................................................................. 7 OPIOID ANALGESICS ................................................................................................................................................................................... 7 NON-OPIOID ANALGESICS.......................................................................................................................................................................... 8 ANTI-INFECTIVES ................................................................................................................................................................................................... 8 ANTIBACTERIALS ......................................................................................................................................................................................... 9 ANTIFUNGALS .............................................................................................................................................................................................. 9 ANTIMALARIALS ......................................................................................................................................................................................... 10 ANTIRETROVIRAL AGENTS ...................................................................................................................................................................... 10 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 11 ANTIVIRALS................................................................................................................................................................................................. 11 MISCELLANEOUS ....................................................................................................................................................................................... 11 ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 12 ALKYLATING AGENTS ............................................................................................................................................................................... 12 ANTIMETABOLITES .................................................................................................................................................................................... 12 HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 12 IMMUNOMODULATORS ............................................................................................................................................................................. 12 KINASE INHIBITORS ................................................................................................................................................................................... 12 TOPOISOMERASE INHIBITORS ................................................................................................................................................................ 13 MISCELLANEOUS ....................................................................................................................................................................................... 13 CARDIOVASCULAR .............................................................................................................................................................................................. 13 ACE INHIBITORS......................................................................................................................................................................................... 13 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 13 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 14 ADRENOLYTICS, CENTRAL....................................................................................................................................................................... 14 ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 14 ALPHA BLOCKERS ..................................................................................................................................................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ......................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ....................................... 14 ANTIARRHYTHMICS ................................................................................................................................................................................... 15 ANTILIPEMICS............................................................................................................................................................................................. 15 BETA-BLOCKERS ....................................................................................................................................................................................... 16 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 16 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 16 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ............................................................................................................ 16 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 16 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ....................................................................................................................... 17 DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ...................................................................................... 17 DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS .................................................................... 17 DIURETICS .................................................................................................................................................................................................. 17 NITRATES .................................................................................................................................................................................................... 17 NITRATE/VASODILATOR COMBINATIONS .............................................................................................................................................. 18 PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 18 MISCELLANEOUS ....................................................................................................................................................................................... 18 1
CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 18 ANTIANXIETY .............................................................................................................................................................................................. 18 ANTICONVULSANTS .................................................................................................................................................................................. 18 ANTIDEMENTIA ........................................................................................................................................................................................... 19 ANTIDEPRESSANTS .................................................................................................................................................................................. 19 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 20 ANTIPSYCHOTICS ...................................................................................................................................................................................... 20 ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 21 FIBROMYALGIA........................................................................................................................................................................................... 21 HUNTINGTON'S DISEASE AGENTS .......................................................................................................................................................... 21 HYPNOTICS................................................................................................................................................................................................. 21 MIGRAINE .................................................................................................................................................................................................... 22 MOOD STABILIZERS .................................................................................................................................................................................. 22 MULTIPLE SCLEROSIS AGENTS .............................................................................................................................................................. 22 MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 22 MYASTHENIA GRAVIS ............................................................................................................................................................................... 23 NARCOLEPSY ............................................................................................................................................................................................. 23 POSTHERPETIC NEURALGIA (PHN)......................................................................................................................................................... 23 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 23 ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 23 ANDROGENS .............................................................................................................................................................................................. 23 ANTIDIABETICS .......................................................................................................................................................................................... 24 CALCIUM REGULATORS ........................................................................................................................................................................... 25 CONTRACEPTIVES .................................................................................................................................................................................... 25 ENDOMETRIOSIS ....................................................................................................................................................................................... 27 ESTROGENS ............................................................................................................................................................................................... 27 ESTROGEN/PROGESTINS ......................................................................................................................................................................... 27 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ............................................................................. 27 FERTILITY REGULATORS.......................................................................................................................................................................... 28 GLUCOCORTICOIDS .................................................................................................................................................................................. 28 GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 28 HUMAN GROWTH HORMONES ................................................................................................................................................................. 28 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 28 PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 28 PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 28 PROGESTINS .............................................................................................................................................................................................. 29 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 29 THYROID AGENTS ..................................................................................................................................................................................... 29 VASOPRESSINS ......................................................................................................................................................................................... 29 MISCELLANEOUS ....................................................................................................................................................................................... 29 GASTROINTESTINAL ........................................................................................................................................................................................... 29 ANTIDIARRHEALS ...................................................................................................................................................................................... 29 ANTIEMETICS ............................................................................................................................................................................................. 29 ANTISPASMODICS ..................................................................................................................................................................................... 30 CHOLELITHOLYTICS .................................................................................................................................................................................. 30 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 30 INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 30 IRRITABLE BOWEL SYNDROME ............................................................................................................................................................... 30 LAXATIVES .................................................................................................................................................................................................. 31 OPIOID-INDUCED CONSTIPATION ........................................................................................................................................................... 31 PANCREATIC ENZYMES ............................................................................................................................................................................ 31 PROSTAGLANDINS .................................................................................................................................................................................... 31 PROTON PUMP INHIBITORS ..................................................................................................................................................................... 31 SALIVA STIMULANTS ................................................................................................................................................................................. 31 STEROIDS, RECTAL ................................................................................................................................................................................... 32 ULCER THERAPY COMBINATIONS .......................................................................................................................................................... 32 MISCELLANEOUS ....................................................................................................................................................................................... 32 GENITOURINARY .................................................................................................................................................................................................. 32 BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 32 URINARY ANTISPASMODICS .................................................................................................................................................................... 32 VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 32 MISCELLANEOUS ....................................................................................................................................................................................... 32 HEMATOLOGIC ..................................................................................................................................................................................................... 33 ANTICOAGULANTS .................................................................................................................................................................................... 33 HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 33 2
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...................................................................................................................... 33 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ........................................................................................................ 33 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 33 PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 33 STEM CELL MOBILIZERS ........................................................................................................................................................................... 34 MISCELLANEOUS ....................................................................................................................................................................................... 34 IMMUNOLOGIC AGENTS...................................................................................................................................................................................... 34 ALLERGENIC EXTRACTS .......................................................................................................................................................................... 34 BIOLOGIC DISEASE-MODIFYING AGENTS .............................................................................................................................................. 34 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 34 IMMUNOMODULATORS ............................................................................................................................................................................. 34 IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 34 NUTRITIONAL/SUPPLEMENTS............................................................................................................................................................................ 35 ELECTROLYTES ......................................................................................................................................................................................... 35 VITAMINS AND MINERALS ........................................................................................................................................................................ 35 RESPIRATORY ...................................................................................................................................................................................................... 35 ANAPHYLAXIS TREATMENT AGENTS ..................................................................................................................................................... 35 ANTICHOLINERGICS .................................................................................................................................................................................. 36 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................ 36 ANTIHISTAMINES, LOW SEDATING.......................................................................................................................................................... 36 ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 36 ANTITUSSIVES............................................................................................................................................................................................ 36 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 36 BETA AGONISTS ........................................................................................................................................................................................ 36 CYSTIC FIBROSIS ...................................................................................................................................................................................... 37 LEUKOTRIENE RECEPTOR ANTAGONISTS ............................................................................................................................................ 37 MAST CELL STABILIZERS ......................................................................................................................................................................... 37 NASAL ANTIHISTAMINES .......................................................................................................................................................................... 37 NASAL STEROIDS ...................................................................................................................................................................................... 37 PHOSPHODIESTERASE-4 INHIBITORS .................................................................................................................................................... 37 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 37 STEROID INHALANTS ................................................................................................................................................................................ 37 XANTHINES ................................................................................................................................................................................................. 37 MISCELLANEOUS ....................................................................................................................................................................................... 37 TOPICAL ................................................................................................................................................................................................................ 38 DERMATOLOGY.......................................................................................................................................................................................... 38 MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 41 OPHTHALMIC .............................................................................................................................................................................................. 41 OTIC ............................................................................................................................................................................................................. 43 WEBSITES ............................................................................................................................................................................................................. 44 INDEX ..................................................................................................................................................................................................................... 46
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INTRODUCTION We are pleased to provide the 2015 Arkansas Blue Cross and Blue Shield Value Formulary as a useful reference and informational tool. The Value Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for their patients. The drugs represented have been reviewed by a National Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The Value Formulary is reflective of current medical practice as of the date of review. The information contained in this Value Formulary and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This Value Formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in the Value Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information. National guidelines can be found on the National Guideline Clearinghouse site at http://www.guideline.gov, on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication.
PREFACE The Value Formulary is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the Value Formulary. Generics should be considered the first line of prescribing. Individual pharmacy benefit plans may impose restrictions or not reimburse some products. In addition, overthe-counter (OTC) products, with the exception of insulin and diabetes monitoring products, are usually not included in the pharmacy benefit. Pharmacy law requires a valid prescription for the purchase of needles and syringes in certain states. OTC products are listed for informational purposes. If covered in the pharmacy benefit, OTC products require a valid prescription. Drugs represented in the Value Formulary may have varying cost to the plan member. Generic medications typically are available at the lowest cost, brand-name medications on the Value Formulary will generally cost more than generics, and brand-name medications not on the list will generally cost the most. The tiered format places drugs into tiers or levels of cost sharing by the plan member in the following manner: Tier 1: Tier 2: Tier 3:
Lowest plan member copayment: All generic drugs, including those on the Value Formulary. Intermediate plan member copayment: Preferred brand-name products on the Value Formulary selected for Tier 2. Highest plan member copayment: Brand-name products on the Value Formulary not selected for Tier 2, and all non-preferred brand-name products. In most cases, there will be reasonable alternatives in Tier 1 or Tier 2 for products found in this highest tier.
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PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The services of an independent National Pharmacy and Therapeutics Committee ("P&T Committee") are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of experts from across the United States. The P&T Committee's voting members include physicians, pharmacists, a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Employees with significant clinical expertise are invited to meet with the P&T Committee, but no employee may vote on issues before the P&T Committee. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers. Arkansas Blue Cross will utilize the services of the independent National P&T Committee as well as internal pharmacy and medical advisory committees to direct formulary decisions as it relates to our benefit certificates and policies.
DRUG LIST PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are on the Value Formulary, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the book. Any exceptions are noted. Products on the Value Formulary include all strengths and dosage forms of the cited brand-name product. pregabalin Lyrica Oral capsules, oral solution and all strengths of Lyrica would be included in this listing. When a strength or dosage form is specified, only the specified strength and dosage form is on the Value Formulary. Other strengths/dosage forms of the reference product are not. acyclovir caps, tabs Zovirax The capsules and tablets of Zovirax are on the Value Formulary. From this entry, the cream and ointment cannot be assumed to be on the list unless there is a specific entry. Extended-release and delayed-release products require their own entry. sitagliptin/metformin Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR. sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the Value Formulary. Dosage forms on the Value Formulary will be consistent with the category and use where listed. neomycin/polymyxin B/hydrocortisone Cortisporin Since Cortisporin is listed only in the OTIC section, it is limited to the otic solution and suspension. From this entry the topical cream cannot be assumed to be on the list unless there is an entry for this product in the DERMATOLOGY section of the Value Formulary.
GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In addition, boldface type may indicate that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora. One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:
Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs.
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Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug. Generics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug. Manufactured in the same strength and dosage form as the brand-name drugs.
When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug. Brand-name drugs having a generic available may:
Incur higher copayment (tier 3) Require payment of the difference in price between generic and brand, in addition to copayment Require mandatory generic dispensing
LEGEND † OTC PA QL SGM ST boldface delayed-rel ext-rel
Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification Extended-release (also known as sustained-release), refer to the reference brand listed for clarification
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ANALGESICS Practice guidelines of pain management are available at: http://www.asahq.org NSAIDs diclofenac sodium delayed-rel diflunisal etodolac ibuprofen nabumetone meloxicam naproxen naproxen sodium oxaprozin sulindac
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
NSAIDs, COMBINATIONS diclofenac sodium delayed-rel/misoprostol
Tier 1
NSAIDs, TOPICAL diclofenac sodium soln ST diclofenac sodium gel
Tier 1 Tier 2 VOLTAREN GEL
COX-2 INHIBITORS celecoxib
Tier 3 CELEBREX
MOBIC NAPROSYN ANAPROX DAYPRO CLINORIL
GOUT probenecid colchicine febuxostat allopurinol
Tier 1 Tier 2 COLCRYS Tier 2 ULORIC Tier 3 ZYLOPRIM
OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: http://www.asahq.org http://www.nccn.org Opioid guidelines in the management of chronic non-malignant pain are available at: http://www.asipp.org/Guidelines.htm PA
PA PA LEGEND boldface † OTC PA QL SGM ST
fentanyl transmucosal lozenge methadone morphine morphine supp oxycodone caps, tabs 5 mg oxycodone concentrate 20 mg/mL tramadol ext-rel buprenorphine transdermal fentanyl citrate buccal fentanyl sublingual spray
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 BUTRANS Tier 2 FENTORA Tier 2 SUBSYS
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 7
PA QL QL QL QL
QL QL QL
fentanyl sublingual tabs oxycodone ext-rel oxymorphone ext-rel tapentadol tapentadol ext-rel codeine/acetaminophen fentanyl transdermal hydrocodone/acetaminophen hydromorphone hydromorphone ext-rel morphine ext-rel morphine ext-rel morphine ext-rel oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL oxycodone/acetaminophen 5/325 tramadol
NON-OPIOID ANALGESICS butalbital/acetaminophen/caffeine tabs butalbital/aspirin/caffeine
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
ABSTRAL OXYCONTIN OPANA ER NUCYNTA NUCYNTA ER TYLENOL w/CODEINE DURAGESIC NORCO DILAUDID EXALGO AVINZA KADIAN MS CONTIN ROXICODONE PERCOCET ULTRAM
Tier 2 ESGIC Tier 2 FIORINAL
ANTI-INFECTIVES Hepatitis: CDC recommendations on the treatment of hepatitis are available at: http://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: http://www.aasld.org HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: http://www.aidsinfo.nih.gov Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: http://www.myamericanheart.org Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm International Travel: CDC recommendations for international travel are available at: http://www.cdc.gov/travel Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: http://www.cdc.gov/std/treatment/default.htm Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: http://www.cdc.gov/flu/ Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: http://www.idsociety.org
LEGEND boldface † OTC PA QL SGM ST
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 8
ANTIBACTERIALS Cephalosporins First Generation cefadroxil cephalexin
Tier 1 Tier 3 KEFLEX
Second Generation cefprozil cefuroxime axetil
Tier 1 Tier 3 CEFTIN
Third Generation cefdinir cefixime
Tier 1 Tier 2 SUPRAX
Erythromycins/Macrolides erythromycin delayed-rel erythromycin stearate erythromycin/sulfisoxazole fidaxomicin azithromycin clarithromycin clarithromycin ext-rel erythromycin ethylsuccinate
Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3
Fluoroquinolones ciprofloxacin ext-rel ciprofloxacin levofloxacin moxifloxacin
Tier 1 Tier 3 CIPRO Tier 3 LEVAQUIN Tier 3 AVELOX
DIFICID ZITHROMAX BIAXIN BIAXIN XL E.E.S.
Penicillins amoxicillin amoxicillin/clavulanate ext-rel ampicillin dicloxacillin penicillin VK amoxicillin/clavulanate
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 AUGMENTIN
Tetracyclines doxycycline hyclate 20 mg tetracycline doxycycline hyclate minocycline
Tier 1 Tier 1 Tier 3 VIBRAMYCIN Tier 3 MINOCIN
ANTIFUNGALS clotrimazole troches nystatin griseofulvin ultramicrosize PA voriconazole fluconazole PA itraconazole
Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 3
LEGEND boldface † OTC PA QL SGM ST
GRIS-PEG VFEND DIFLUCAN SPORANOX
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 9
terbinafine tabs
Tier 3 LAMISIL
ANTIMALARIALS mefloquine artemether/lumefantrine atovaquone/proguanil chloroquine
Tier 1 Tier 2 COARTEM Tier 2 MALARONE Tier 2 ARALEN
ANTIRETROVIRAL AGENTS Antiretroviral Combinations abacavir/dolutegravir/lamivudine abacavir/lamivudine atazanavir/cobicistat darunavir/cobicistat efavirenz/emtricitabine/tenofovir elvitegravir/cobicistat/emtricitabine/tenofovir emtricitabine/rilpivirine/tenofovir emtricitabine/tenofovir lamivudine/zidovudine
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3
Fusion Inhibitors enfuvirtide
Tier 2 FUZEON
Integrase Inhibitors dolutegravir raltegravir
Tier 2 TIVICAY Tier 2 ISENTRESS
Non-nucleoside Reverse Transcriptase Inhibitors delavirdine efavirenz etravirine nevirapine nevirapine ext-rel rilpivirine
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
RESCRIPTOR SUSTIVA INTELENCE VIRAMUNE VIRAMUNE XR EDURANT
Nucleoside Reverse Transcriptase Inhibitors didanosine delayed-rel emtricitabine stavudine zidovudine abacavir tabs lamivudine
Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3
VIDEX EC EMTRIVA ZERIT RETROVIR ZIAGEN tabs EPIVIR
Nucleotide Reverse Transcriptase Inhibitors tenofovir
Tier 2 VIREAD
Protease Inhibitors atazanavir darunavir lopinavir/ritonavir ritonavir
Tier 2 Tier 2 Tier 2 Tier 2
LEGEND boldface † OTC PA QL SGM ST
TRIUMEQ EPZICOM EVOTAZ PREZCOBIX ATRIPLA STRIBILD COMPLERA TRUVADA COMBIVIR
REYATAZ PREZISTA KALETRA NORVIR
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 10
ANTITUBERCULAR AGENTS isoniazid pyrazinamide ethambutol rifampin
Tier 1 Tier 1 Tier 2 MYAMBUTOL Tier 2 RIFADIN
ANTIVIRALS Cytomegalovirus Agents valganciclovir
Tier 2 VALCYTE
Hepatitis Agents Hepatitis B entecavir lamivudine
Tier 2 BARACLUDE Tier 2 EPIVIR-HBV
Hepatitis C SGM ribavirin caps SGM ribavirin oral soln SGM ribavirin tabs
Tier 2 REBETOL Tier 2 REBETOL Tier 2 COPEGUS
Herpes Agents valacyclovir acyclovir caps, tabs famciclovir
Tier 1 Tier 3 ZOVIRAX Tier 3 FAMVIR
Influenza Agents QL oseltamivir QL zanamivir
Tier 2 TAMIFLU Tier 2 RELENZA
MISCELLANEOUS dapsone sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim DS trimethoprim albendazole clindamycin nitazoxanide nitrofurantoin ext-rel nitrofurantoin macrocrystals nitrofurantoin susp rifaximin tedizolid tinidazole vancomycin ivermectin metronidazole
Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3
LEGEND boldface † OTC PA QL SGM ST
ALBENZA CLEOCIN ALINIA MACROBID MACRODANTIN FURADANTIN XIFAXAN 550 mg SIVEXTRO TINDAMAX VANCOCIN STROMECTOL FLAGYL
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 11
ANTINEOPLASTIC AGENTS Clinical practice guidelines in oncology are available at: http://www.asco.org http://www.nccn.org ALKYLATING AGENTS altretamine busulfan chlorambucil cyclophosphamide caps lomustine melphalan SGM temozolomide
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
ANTIMETABOLITES mercaptopurine SGM capecitabine methotrexate thioguanine
Tier 1 Tier 2 XELODA Tier 2 TREXALL Tier 2 TABLOID
HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens flutamide bicalutamide
Tier 1 Tier 2 CASODEX
Antiestrogens tamoxifen
Tier 1
Aromatase Inhibitors anastrozole exemestane letrozole
Tier 2 ARIMIDEX Tier 2 AROMASIN Tier 2 FEMARA
Luteinizing Hormone-releasing Hormone (LHRH) Agonists † leuprolide acetate † goserelin acetate † leuprolide acetate † triptorelin pamoate
HEXALEN MYLERAN LEUKERAN CYCLOPHOSPHAMIDE caps CEENU ALKERAN TEMODAR
ZOLADEX LUPRON DEPOT TRELSTAR
Progestins megestrol acetate
Tier 2 MEGACE
IMMUNOMODULATORS SGM lenalidomide SGM pomalidomide SGM thalidomide
Tier 2 REVLIMID Tier 2 POMALYST Tier 2 THALOMID
KINASE INHIBITORS SGM bosutinib SGM dasatinib
Tier 2 BOSULIF Tier 2 SPRYCEL
LEGEND boldface † OTC PA QL SGM ST
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 12
SGM SGM SGM SGM SGM SGM SGM SGM
erlotinib everolimus imatinib mesylate lapatinib pazopanib ponatinib sorafenib sunitinib
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
TARCEVA AFINITOR GLEEVEC TYKERB VOTRIENT ICLUSIG NEXAVAR SUTENT
TOPOISOMERASE INHIBITORS SGM topotecan caps
Tier 2 HYCAMTIN caps
MISCELLANEOUS etoposide tretinoin caps SGM bexarotene caps hydroxyurea mitotane procarbazine SGM vorinostat
Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
TARGRETIN caps HYDREA LYSODREN MATULANE ZOLINZA
CARDIOVASCULAR The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: http://www.acc.org http://www.heartfailureguideline.org http://www.myamericanheart.org ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://professional.diabetes.org http://www.acc.org http://www.myamericanheart.org captopril fosinopril benazepril enalapril lisinopril perindopril quinapril ramipril trandolapril ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril trandolapril/verapamil ext-rel LEGEND boldface † OTC PA QL SGM ST
Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
LOTENSIN VASOTEC ZESTRIL ACEON ACCUPRIL ALTACE MAVIK
Tier 2 LOTREL Tier 2 TARKA
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 13
ACE INHIBITOR/DIURETIC COMBINATIONS captopril/hydrochlorothiazide fosinopril/hydrochlorothiazide benazepril/hydrochlorothiazide enalapril/hydrochlorothiazide lisinopril/hydrochlorothiazide quinapril/hydrochlorothiazide
Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3
ADRENOLYTICS, CENTRAL clonidine clonidine transdermal guanfacine
Tier 2 CATAPRES Tier 2 CATAPRES-TTS Tier 2 TENEX
ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone spironolactone
Tier 2 INSPRA Tier 2 ALDACTONE
LOTENSIN HCT VASERETIC ZESTORETIC ACCURETIC
ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 terazosin doxazosin
Tier 1 Tier 3 CARDURA
ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://professional.diabetes.org
ST ST
candesartan candesartan/hydrochlorothiazide eprosartan irbesartan irbesartan/hydrochlorothiazide valsartan/hydrochlorothiazide olmesartan olmesartan/hydrochlorothiazide losartan losartan/hydrochlorothiazide telmisartan telmisartan/hydrochlorothiazide valsartan
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3
BENICAR BENICAR HCT COZAAR HYZAAR MICARDIS MICARDIS HCT
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/telmisartan Tier 1 amlodipine/olmesartan Tier 2 AZOR amlodipine/valsartan ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS olmesartan/amlodipine/hydrochlorothiazide Tier 2 TRIBENZOR amlodipine/valsartan/hydrochlorothiazide LEGEND boldface † OTC PA QL SGM ST
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 14
ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: http://www.acc.org amiodarone disopyramide disopyramide ext-rel dofetilide flecainide propafenone propafenone ext-rel sotalol sotalol
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
CORDARONE NORPACE NORPACE CR TIKOSYN TAMBOCOR RYTHMOL RYTHMOL SR BETAPACE BETAPACE AF
ANTILIPEMICS The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults is available at: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a Bile Acid Resins colesevelam cholestyramine colestipol
Tier 2 WELCHOL Tier 3 QUESTRAN/QUESTRAN LIGHT Tier 3 COLESTID
Cholesterol Absorption Inhibitors ezetimibe
Tier 2 ZETIA
Fibrates fenofibrate fenofibrate fenofibrate fenofibrate fenofibric acid delayed-rel gemfibrozil HMG-CoA Reductase Inhibitors/Combinations atorvastatin fluvastatin ST ezetimibe/simvastatin ST, * rosuvastatin lovastatin pravastatin simvastatin
Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
ANTARA LIPOFEN LOFIBRA TRILIPIX LOPID
Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3
VYTORIN CRESTOR MEVACOR PRAVACHOL ZOCOR
* Step Therapy does not include 40 mg strength Niacins/Combinations ST niacin ext-rel/simvastatin niacin ext-rel
LEGEND boldface † OTC PA QL SGM ST
Tier 2 SIMCOR Tier 3 NIASPAN
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 15
Omega-3 Fatty Acids omega-3 acid ethyl esters
Tier 3 LOVAZA
BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://www.acc.org labetalol pindolol propranolol carvedilol phosphate ext-rel nebivolol atenolol bisoprolol carvedilol metoprolol succinate ext-rel metoprolol tartrate nadolol propranolol ext-rel
Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
COREG CR BYSTOLIC TENORMIN ZEBETA COREG TOPROL-XL LOPRESSOR CORGARD INDERAL LA
BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://www.acc.org atenolol/chlorthalidone bisoprolol/hydrochlorothiazide metoprolol/hydrochlorothiazide
Tier 2 TENORETIC Tier 2 ZIAC Tier 2 LOPRESSOR HCT
CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine felodipine ext-rel nifedipine ext-rel nifedipine ext-rel
Tier 1 Tier 1 Tier 3 ADALAT CC Tier 3 PROCARDIA XL
Nondihydropyridines diltiazem ext-rel diltiazem ext-rel verapamil ext-rel
Tier 3 TIAZAC Tier 3 CALAN SR
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin
Tier 3 CADUET
DIGITALIS GLYCOSIDES digoxin ped elixir digoxin
Tier 1 Tier 2 LANOXIN
LEGEND boldface † OTC PA QL SGM ST
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 16
DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ST aliskiren ST aliskiren/hydrochlorothiazide
Tier 2 TEKTURNA Tier 2 TEKTURNA HCT
DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS aliskiren/amlodipine Tier 2 TEKAMLO DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS aliskiren/amlodipine/hydrochlorothiazide Tier 2 AMTURNIDE DIURETICS Carbonic Anhydrase Inhibitors acetazolamide methazolamide acetazolamide ext-rel
Tier 1 Tier 1 Tier 2 DIAMOX SEQUELS
Loop Diuretics bumetanide furosemide torsemide
Tier 1 Tier 3 LASIX Tier 3 DEMADEX
Potassium-sparing Diuretics amiloride
Tier 1
Thiazides and Thiazide-like Diuretics chlorthalidone hydrochlorothiazide indapamide metolazone
Tier 1 Tier 1 Tier 1 Tier 3 ZAROXOLYN
Diuretic Combinations amiloride/hydrochlorothiazide spironolactone/hydrochlorothiazide triamterene/hydrochlorothiazide triamterene/hydrochlorothiazide
Tier 1 Tier 3 ALDACTAZIDE Tier 3 DYAZIDE Tier 3 MAXZIDE
NITRATES Oral isosorbide dinitrate ext-rel tabs isosorbide mononitrate isosorbide dinitrate oral isosorbide mononitrate ext-rel
Tier 1 Tier 1 Tier 2 ISORDIL Tier 2 IMDUR
Sublingual/Translingual nitroglycerin lingual spray nitroglycerin sublingual
Tier 2 NITROLINGUAL Tier 2 NITROSTAT
Transdermal nitroglycerin transdermal nitroglycerin transdermal
Tier 1 Tier 2 NITRO-DUR
LEGEND boldface † OTC PA QL SGM ST
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 17
NITRATE/VASODILATOR COMBINATIONS isosorbide dinitrate/hydralazine
Tier 2 BIDIL
PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists SGM ambrisentan SGM bosentan
Tier 2 LETAIRIS Tier 2 TRACLEER
Phosphodiesterase Inhibitors SGM tadalafil SGM sildenafil
Tier 2 ADCIRCA Tier 3 REVATIO
Prostaglandin Vasodilators † epoprostenol sodium SGM iloprost SGM treprostinil SGM treprostinil
FLOLAN Tier 2 VENTAVIS Tier 2 REMODULIN Tier 2 TYVASO
MISCELLANEOUS hydralazine methyldopa midodrine ranolazine ext-rel
Tier 1 Tier 1 Tier 1 Tier 2 RANEXA
CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: http://www.psych.org ANTIANXIETY Benzodiazepines oxazepam alprazolam clonazepam tabs diazepam lorazepam
Tier 1 Tier 2 Tier 2 Tier 2 Tier 2
Miscellaneous buspirone fluvoxamine clomipramine
Tier 1 Tier 1 Tier 2 ANAFRANIL
XANAX KLONOPIN VALIUM ATIVAN
ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: http://www.aan.com PA
LEGEND boldface † OTC PA QL SGM ST
phenobarbital lacosamide lamotrigine ext-rel tiagabine carbamazepine
Tier 1 Tier 2 Tier 2 Tier 2 Tier 3
VIMPAT LAMICTAL XR GABITRIL TEGRETOL
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 18
carbamazepine ext-rel carbamazepine ext-rel diazepam rectal gel divalproex sodium delayed-rel divalproex sodium ext-rel ethosuximide gabapentin lamotrigine lamotrigine orally disintegrating tabs levetiracetam levetiracetam ext-rel oxcarbazepine phenytoin phenytoin sodium extended primidone topiramate valproic acid zonisamide
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
CARBATROL TEGRETOL-XR DIASTAT DEPAKOTE DEPAKOTE ER ZARONTIN NEURONTIN LAMICTAL LAMICTAL ODT KEPPRA KEPPRA XR TRILEPTAL DILANTIN INFATABS DILANTIN MYSOLINE TOPAMAX DEPAKENE ZONEGRAN
Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3
NAMENDA NAMENDA XR EXELON PATCH ARICEPT RAZADYNE RAZADYNE ER EXELON
ANTIDEMENTIA Practice guidelines for the management of dementia are available at: http://www.aan.com memantine memantine ext-rel rivastigmine transdermal donepezil galantamine galantamine ext-rel rivastigmine
ANTIDEPRESSANTS Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder. Guidelines for the evaluation and management of bipolar and depressive disorders are available at: http://www.psych.org Monoamine Oxidase Inhibitors (MAOIs) phenelzine tranylcypromine
Tier 2 NARDIL Tier 2 PARNATE
Selective Serotonin Reuptake Inhibitors (SSRIs) fluoxetine ST vilazodone ST vortioxetine citalopram escitalopram fluoxetine paroxetine HCl paroxetine HCl ext-rel
Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
LEGEND boldface † OTC PA QL SGM ST
FLUOXETINE 60 mg VIIBRYD BRINTELLIX CELEXA LEXAPRO PROZAC PAXIL PAXIL CR
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 19
sertraline Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) venlafaxine ST desvenlafaxine ext-rel ST desvenlafaxine ext-rel duloxetine delayed-rel venlafaxine ext-rel
Tier 3 ZOLOFT Tier 1 Tier 2 KHEDEZLA Tier 2 PRISTIQ Tier 3 EFFEXOR XR
Tricyclic Antidepressants (TCAs) amitriptyline doxepin desipramine imipramine HCl nortriptyline
Tier 1 Tier 1 Tier 2 NORPRAMIN Tier 2 TOFRANIL Tier 2 PAMELOR
Miscellaneous Agents trazodone bupropion bupropion ext-rel bupropion ext-rel mirtazapine
Tier 1 Tier 3 Tier 3 Tier 3 Tier 3
WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL REMERON
ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: http://www.aan.com amantadine benztropine selegiline trihexyphenidyl bromocriptine pramipexole ext-rel rasagiline mesylate rotigotine transdermal selegiline orally disintegrating tabs carbidopa/levodopa carbidopa/levodopa ext-rel carbidopa/levodopa orally disintegrating tabs carbidopa/levodopa/entacapone entacapone pramipexole ropinirole ropinirole ext-rel ANTIPSYCHOTICS Atypicals † aripiprazole inj lurasidone quetiapine ext-rel † risperidone long-acting injection LEGEND boldface † OTC PA QL SGM ST
Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
PARLODEL MIRAPEX ER AZILECT NEUPRO ZELAPAR SINEMET SINEMET CR PARCOPA STALEVO COMTAN MIRAPEX REQUIP REQUIP XL
ABILIFY injection Tier 2 LATUDA Tier 2 SEROQUEL XR RISPERDAL CONSTA
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 20
aripiprazole clozapine olanzapine quetiapine risperidone ziprasidone Miscellaneous chlorpromazine fluphenazine haloperidol perphenazine thiothixene trifluoperazine
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
CLOZARIL ZYPREXA SEROQUEL RISPERDAL GEODON
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: http://www.aacap.org http://www.aap.org amphetamine/dextroamphetamine mixed salts amphetamine/dextroamphetamine mixed salts ext-rel dextroamphetamine methylphenidate ext-rel 10 mg atomoxetine lisdexamfetamine methylphenidate ext-rel susp methylphenidate transdermal dexmethylphenidate dexmethylphenidate ext-rel dextroamphetamine ext-rel guanfacine ext-rel methylphenidate methylphenidate methylphenidate ext-rel methylphenidate ext-rel
Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3
STRATTERA VYVANSE QUILLIVANT XR DAYTRANA FOCALIN FOCALIN XR DEXEDRINE SPANSULE
Tier 3 Tier 3 Tier 3 Tier 3
METHYLIN RITALIN CONCERTA RITALIN LA
FIBROMYALGIA milnacipran pregabalin
Tier 2 SAVELLA Tier 2 LYRICA
HUNTINGTON'S DISEASE AGENTS SGM tetrabenazine
Tier 2 XENAZINE
HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at: http://www.aasmnet.org Benzodiazepines temazepam LEGEND boldface † OTC PA QL SGM ST
Tier 3 RESTORIL
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 21
Nonbenzodiazepines eszopiclone zolpidem zolpidem ext-rel
Tier 1 Tier 3 AMBIEN Tier 3 AMBIEN CR
Tricyclics ST doxepin
Tier 2 SILENOR
MIGRAINE Guidelines for prevention and management of migraine headaches are available at: http://www.aan.com Ergotamine Derivatives dihydroergotamine inj QL dihydroergotamine spray
Tier 2 D.H.E. 45 Tier 2 MIGRANAL
Selective Serotonin Agonists QL naratriptan ST, QL eletriptan ST, QL sumatriptan inj QL zolmitriptan nasal spray QL rizatriptan QL sumatriptan QL sumatriptan inj QL sumatriptan nasal spray QL zolmitriptan
Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
RELPAX SUMAVEL DOSEPRO ZOMIG MAXALT IMITREX IMITREX IMITREX ZOMIG
Selective Serotonin Agonist/Nonsteroidal Anti-inflammatory Drug (NSAID) Combinations ST, QL sumatriptan/naproxen sodium Tier 2 TREXIMET MOOD STABILIZERS lithium carbonate lithium carbonate ext-rel tabs 450 mg lithium carbonate ext-rel tabs 300 mg
Tier 1 Tier 1 Tier 2 LITHOBID
MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at: http://www.aan.com SGM SGM SGM SGM SGM
dimethyl fumarate delayed-rel fingolimod glatiramer interferon beta-1a teriflunomide
MUSCULOSKELETAL THERAPY AGENTS baclofen carisoprodol cyclobenzaprine orphenadrine/aspirin/caffeine chlorzoxazone LEGEND boldface † OTC PA QL SGM ST
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
TECFIDERA GILENYA COPAXONE REBIF AUBAGIO
Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 PARAFON FORTE DSC
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 22
dantrolene metaxalone methocarbamol tizanidine
Tier 2 Tier 2 Tier 2 Tier 2
DANTRIUM SKELAXIN ROBAXIN ZANAFLEX tabs
MYASTHENIA GRAVIS pyridostigmine pyridostigmine ext-rel
Tier 2 MESTINON Tier 2 MESTINON TIMESPAN
NARCOLEPSY PA armodafinil
Tier 2 NUVIGIL
POSTHERPETIC NEURALGIA (PHN) gabapentin ext-rel
Tier 2 GRALISE
PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents acamprosate calcium disulfiram
Tier 2 CAMPRAL Tier 2 ANTABUSE
Opioid Antagonists naloxone naltrexone
Tier 2 EVZIO Tier 2 REVIA
Partial Opioid Agonist/Opioid Antagonist Combinations PA buprenorphine/naloxone sublingual tabs PA buprenorphine/naloxone sublingual film
Tier 1 Tier 2 SUBOXONE FILM
Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html bupropion ext-rel varenicline Vasomotor Symptom Agents paroxetine mesylate
Tier 2 ZYBAN Tier 2 CHANTIX Tier 2 BRISDELLE
ENDOCRINE AND METABOLIC ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: http://www.aace.com † † PA PA PA
LEGEND boldface † OTC PA QL SGM ST
testosterone cypionate testosterone enanthate testosterone gel testosterone soln testosterone transdermal
Tier 2 AXIRON Tier 2 ANDRODERM
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 23
ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: http://professional.diabetes.org Alpha-glucosidase Inhibitors acarbose
Tier 2 PRECOSE
Amylin Analogs pramlintide
Tier 2 SYMLINPEN
Biguanides metformin metformin ext-rel
Tier 3 GLUCOPHAGE Tier 3 GLUCOPHAGE XR
Biguanide/Sulfonylurea Combinations glipizide/metformin
Tier 3 METAGLIP
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors linagliptin sitagliptin phosphate
Tier 2 TRADJENTA Tier 2 JANUVIA
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations linagliptin/metformin sitagliptin/metformin sitagliptin/metformin ext-rel
Tier 2 JENTADUETO Tier 2 JANUMET Tier 2 JANUMET XR
Incretin Mimetic Agents dulaglutide liraglutide
Tier 2 TRULICITY Tier 2 VICTOZA
Insulins
OTC OTC OTC
insulin aspart insulin aspart protamine 70%/insulin aspart 30% insulin detemir insulin glargine insulin glargine insulin human insulin human insulin isophane human insulin isophane human 70%/regular 30%
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
NOVOLOG NOVOLOG MIX 70/30 LEVEMIR LANTUS TOUJEO HUMULIN R U-500 NOVOLIN R NOVOLIN N NOVOLIN 70/30
Insulin Sensitizers pioglitazone
Tier 1
Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin
Tier 3 ACTOPLUS MET
Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride
Tier 3 DUETACT
LEGEND boldface † OTC PA QL SGM ST
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 24
Meglitinides nateglinide repaglinide
Tier 1 Tier 3 PRANDIN
Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors dapagliflozin empagliflozin
Tier 2 FARXIGA Tier 2 JARDIANCE
Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor/Biguanide Combinations dapagliflozin/metformin Tier 2 XIGDUO XR Sulfonylureas glyburide glimepiride glipizide glipizide ext-rel
Tier 1 Tier 3 AMARYL Tier 3 GLUCOTROL Tier 3 GLUCOTROL XL
Supplies OTC
blood glucose continuous monitoring receivers, sensors, transmitters blood glucose monitoring kits, test strips
OTC
blood glucose monitoring kits, test strips
OTC OTC
insulin syringes, needles lancets
Tier 2 DEXCOM G4 Tier 2 ONETOUCH ULTRA kits and test strips Tier 2 ONETOUCH VERIO kits and test strips Tier 2 BD insulin syringes and needles Tier 2 LANCETS
CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: http://www.aace.com http://www.nof.org Bisphosphonates risedronate risedronate delayed-rel alendronate ibandronate
Tier 2 Tier 2 Tier 3 Tier 3
ACTONEL ATELVIA FOSAMAX BONIVA
Calcitonins calcitonin-salmon Parathyroid Hormones SGM teriparatide
Tier 3 MIACALCIN Tier 2 FORTEO
CONTRACEPTIVES EE = ethinyl estradiol ME = mestranol Monophasic 10 mcg Estrogen norethindrone acetate/EE 1/10 and EE 10 and iron LEGEND boldface † OTC PA QL SGM ST
Tier 2 LO LOESTRIN FE
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 25
20 mcg Estrogen levonorgestrel/EE 0.1/20 - Lessina norethindrone acetate/EE 1/20 and iron - Lomedia 24 Fe drospirenone/EE/levomefolate 3/20 and levomefolate norethindrone acetate/EE 1/20 and iron chewable drospirenone/EE 3/20 norethindrone acetate/EE 1/20 norethindrone acetate/EE 1/20 and iron
Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3
BEYAZ MINASTRIN 24 FE YAZ LOESTRIN 1/20 LOESTRIN FE 1/20
30 mcg Estrogen levonorgestrel/EE 0.15/30 - Levora norgestrel/EE 0.3/30 - Low-Ogestrel drospirenone/EE/levomefolate 3/30 and levomefolate desogestrel/EE 0.15/30 drospirenone/EE 3/30 norethindrone acetate/EE 1.5/30 norethindrone acetate/EE 1.5/30 and iron
Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3
SAFYRAL ORTHO-CEPT YASMIN LOESTRIN 1.5/30 LOESTRIN FE 1.5/30
35 mcg Estrogen ethynodiol diacetate/EE 1/35 - Zovia 1/35 norethindrone/EE 0.5/35 norethindrone/EE 0.5/35 norethindrone/EE 1/35 norethindrone/EE 1/35 norgestimate/EE 0.25/35
Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
BREVICON MODICON NORINYL 1+35 ORTHO-NOVUM 1/35 ORTHO-CYCLEN
50 mcg Estrogen ethynodiol diacetate/EE 1/50 - Zovia 1/50 norethindrone/ME 1/50
Tier 1 Tier 3 NORINYL 1+50
Biphasic desogestrel/EE
Tier 2 MIRCETTE
levonorgestrel/EE - Trivora norgestimate/EE desogestrel/EE norethindrone/EE norethindrone/EE norgestimate/EE
Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3
estradiol valerate and dienogest/estradiol valerate
Tier 2 NATAZIA
Triphasic ORTHO TRI-CYCLEN LO CYCLESSA ORTHO-NOVUM 7/7/7 TRI-NORINYL ORTHO TRI-CYCLEN
Four Phase Extended Cycle levonorgestrel/EE 0.15/30 levonorgestrel/EE 0.1/20 and EE 10 levonorgestrel/EE 0.15/30 and EE 10
LEGEND boldface † OTC PA QL SGM ST
Tier 1 Tier 3 LOSEASONIQUE Tier 3 SEASONIQUE
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 26
Progestin Only norethindrone norethindrone
Tier 2 NOR-QD Tier 2 ORTHO MICRONOR
Injectable medroxyprogesterone acetate 150 mg/mL
Tier 2 DEPO-PROVERA
Progestin Intrauterine Device † levonorgestrel releasing IUD Transdermal norelgestromin/EE
MIRENA Tier 3 ORTHO EVRA
Vaginal etonogestrel/EE ring ENDOMETRIOSIS danazol
Tier 2 NUVARING Tier 1
ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: http://www.menopause.org https://www.aace.com/files/menopause.pdf Oral estropipate estrogens, conjugated estradiol Transdermal estradiol estradiol estradiol estradiol estradiol
Tier 1 Tier 2 PREMARIN Tier 3 ESTRACE Tier 2 Tier 2 Tier 2 Tier 3 Tier 3
DIVIGEL EVAMIST MINIVELLE CLIMARA VIVELLE-DOT
Vaginal estradiol vaginal crm estradiol vaginal tabs estrogens, conjugated crm ESTROGEN/PROGESTINS Oral EE/norethindrone acetate - Jinteli estradiol/norethindrone estrogens, conjugated/medroxyprogesterone estrogens, conjugated/medroxyprogesterone
Tier 2 ESTRACE Tier 2 VAGIFEM Tier 2 PREMARIN crm
Tier 1 Tier 1 Tier 2 PREMPHASE Tier 2 PREMPRO
ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS conjugated estrogens/bazedoxifene Tier 2 DUAVEE
LEGEND boldface † OTC PA QL SGM ST
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 27
FERTILITY REGULATORS GNRH/LHRH Antagonists cetrorelix ganirelix
Tier 2 CETROTIDE Tier 2
Ovulation Stimulants, Gonadotropins † chorionic gonadotropin - Novarel choriogonadotropin alfa follitropin beta
Tier 2 OVIDREL Tier 2 FOLLISTIM AQ
Ovulation Stimulants, Synthetic clomiphene
Tier 2 CLOMID
GLUCOCORTICOIDS dexamethasone fludrocortisone prednisolone sodium phosphate prednisolone sodium phosphate 5 mg/5 mL prednisone hydrocortisone methylprednisolone prednisolone syrup
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 CORTEF Tier 2 MEDROL Tier 2 PRELONE
GLUCOSE ELEVATING AGENTS glucagon, human recombinant glucagon, human recombinant
Tier 2 GLUCAGEN HYPOKIT Tier 2 GLUCAGON EMERGENCY KIT
HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: http://www.aace.com/publications/guidelines SGM SGM
somatropin somatropin
Tier 2 HUMATROPE Tier 2 NORDITROPIN
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) doxercalciferol paricalcitol
Tier 2 ROCALTROL Tier 2 HECTOROL Tier 2 ZEMPLAR
PHENYLKETONURIA TREATMENT AGENTS SGM sapropterin
Tier 2 KUVAN
PHOSPHATE BINDER AGENTS calcium acetate tabs calcium acetate sevelamer carbonate sucroferric oxyhydroxide calcium acetate
Tier 1 Tier 2 Tier 2 Tier 2 Tier 3
LEGEND boldface † OTC PA QL SGM ST
PHOSLYRA RENVELA VELPHORO PHOSLO
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 28
PROGESTINS Oral megestrol acetate susp medroxyprogesterone acetate norethindrone acetate progesterone, micronized
Tier 2 Tier 3 Tier 3 Tier 3
MEGACE ES PROVERA AYGESTIN PROMETRIUM
Vaginal progesterone gel progesterone vaginal inserts
Tier 2 CRINONE Tier 2 ENDOMETRIN
SELECTIVE ESTROGEN RECEPTOR MODULATORS ospemifene raloxifene
Tier 2 OSPHENA Tier 3 EVISTA
THYROID AGENTS Antithyroid Agents propylthiouracil methimazole
Tier 1 Tier 2 TAPAZOLE
Thyroid Supplements levothyroxine levothyroxine - Levoxyl levothyroxine liothyronine
Tier 1 Tier 1 Tier 2 SYNTHROID Tier 2 CYTOMEL
VASOPRESSINS desmopressin spray, tabs
Tier 2 DDAVP
MISCELLANEOUS cabergoline levocarnitine
Tier 1 Tier 2 CARNITOR
GASTROINTESTINAL Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: http://gi.org http://www.gastro.org ANTIDIARRHEALS loperamide diphenoxylate/atropine
Tier 1 Tier 2 LOMOTIL
ANTIEMETICS QL granisetron prochlorperazine promethazine doxylamine/pyridoxine delayed-rel PA, QL granisetron transdermal PA, QL dronabinol meclizine
Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 3
LEGEND boldface † OTC PA QL SGM ST
DICLEGIS SANCUSO MARINOL ANTIVERT
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 29
QL
metoclopramide ondansetron trimethobenzamide
Tier 3 REGLAN Tier 3 ZOFRAN Tier 3 TIGAN
ANTISPASMODICS chlordiazepoxide/clidinium hyoscyamine sulfate ext-rel caps hyoscyamine sulfate orally disintegrating tabs dicyclomine hyoscyamine sulfate hyoscyamine sulfate ext-rel
Tier 1 Tier 1 Tier 1 Tier 2 BENTYL Tier 2 LEVSIN Tier 2 LEVBID
CHOLELITHOLYTICS ursodiol ursodiol
Tier 2 ACTIGALL Tier 2 URSO
H2 RECEPTOR ANTAGONISTS cimetidine famotidine ranitidine
Tier 1 Tier 3 PEPCID Tier 3 ZANTAC
INFLAMMATORY BOWEL DISEASE Oral Agents balsalazide budesonide delayed-rel caps budesonide ext-rel mesalamine delayed-rel tabs mesalamine ext-rel caps mesalamine ext-rel caps olsalazine sulfasalazine sulfasalazine delayed-rel
Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3
Rectal Agents hydrocortisone enema hydrocortisone acetate foam mesalamine supp mesalamine rectal susp
Tier 1 Tier 2 CORTIFOAM Tier 2 CANASA Tier 3 ROWASA
IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation linaclotide
Tier 2 LINZESS
LEGEND boldface † OTC PA QL SGM ST
UCERIS LIALDA APRISO PENTASA DIPENTUM AZULFIDINE AZULFIDINE EN-TABS
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 30
Irritable Bowel Syndrome with Diarrhea * alosetron
Tier 2 LOTRONEX
* To prescribe Alosetron Hydrochloride Tablets, the prescriber must be enrolled in the Alosetron REMS Program. To enroll, prescribers must understand the benefits and risks of treatment with Alosetron Hydrochloride Tablets for severe diarrheapredominant IBS, including the information in the Prescribing Information, Medication Guide, and Patient Acknowledgement Form for Alosetron Hydrochloride Tablets. To enroll in the Alosetron REMS Program, call 1-844-267-8675 or visit www.AlosetronREMS.com to complete the Prescriber Enrollment Form. * For safety reasons, to prescribe Lotronex, the physician must be enrolled in the Prescribing Program for Lotronex. Physicians must understand the benefits and risks of treatment with Lotronex for severe diarrhea-predominant IBS, including the information in the Prescribing Information, Medication Guide and Patient-Physician Agreement for Lotronex. To enroll or for more information on the Prescribing Program for Lotronex, call toll-free: 1-888-423-5227 or visit www.lotronex.com to complete the Physician Enrollment Form. LAXATIVES lactulose peg 3350/electrolytes peg 3350/electrolytes polyethylene glycol 3350 sodium sulfate/potassium sulfate/magnesium sulfate peg 3350/electrolytes peg 3350/electrolytes
Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3
MOVIPREP SUCLEAR MIRALAX SUPREP GOLYTELY NULYTELY
OPIOID-INDUCED CONSTIPATION naloxegol
Tier 2 MOVANTIK
PANCREATIC ENZYMES pancrelipase pancrelipase delayed-rel pancrelipase delayed-rel pancrelipase delayed-rel
Tier 2 Tier 2 Tier 2 Tier 2
PROSTAGLANDINS misoprostol
Tier 2 CYTOTEC
PROTON PUMP INHIBITORS lansoprazole delayed-rel omeprazole/sodium bicarbonate caps pantoprazole delayed-rel dexlansoprazole delayed-rel esomeprazole delayed-rel omeprazole delayed-rel
Tier 1 Tier 1 Tier 1 Tier 2 DEXILANT Tier 2 NEXIUM Tier 3 PRILOSEC
SALIVA STIMULANTS cevimeline pilocarpine tabs
Tier 2 EVOXAC Tier 2 SALAGEN
LEGEND boldface † OTC PA QL SGM ST
VIOKACE CREON ULTRESA ZENPEP
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 31
STEROIDS, RECTAL hydrocortisone acetate/pramoxine foam hydrocortisone crm
Tier 2 PROCTOFOAM-HC Tier 2 ANUSOL-HC
ULCER THERAPY COMBINATIONS bismuth/metronidazole/tetracycline lansoprazole + amoxicillin + clarithromycin
Tier 2 PYLERA Tier 2 PREVPAC
MISCELLANEOUS sucralfate
Tier 2 CARAFATE
GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: http://www.auanet.org/guidelines alfuzosin ext-rel dutasteride silodosin finasteride tamsulosin
Tier 1 Tier 2 Tier 2 Tier 3 Tier 3
AVODART RAPAFLO PROSCAR FLOMAX
URINARY ANTISPASMODICS oxybutynin tolterodine ext-rel trospium trospium ext-rel mirabegron ext-rel oxybutynin gel solifenacin succinate oxybutynin ext-rel tolterodine
Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3
MYRBETRIQ GELNIQUE VESICARE DITROPAN XL DETROL
VAGINAL ANTI-INFECTIVES clindamycin crm metronidazole terconazole terconazole
Tier 2 Tier 2 Tier 2 Tier 2
CLEOCIN METROGEL-VAGINAL TERAZOL 3 TERAZOL 7
MISCELLANEOUS bethanechol phenazopyridine potassium citrate ext-rel
Tier 2 URECHOLINE Tier 2 PYRIDIUM Tier 2 UROCIT-K
LEGEND boldface † OTC PA QL SGM ST
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 32
HEMATOLOGIC Guidelines of treatment and management of hemophilia are available at: http://www.hemophilia.org ANTICOAGULANTS CHEST guidelines are available at: http://www.chestnet.org/Guidelines-and-Resources/Guidelines-and-Consensus-Statements/Antithrombotic-Guidelines9th-Ed Injectable dalteparin enoxaparin
Tier 2 FRAGMIN Tier 2 LOVENOX
apixaban dabigatran etexilate rivaroxaban warfarin
Tier 2 Tier 2 Tier 2 Tier 3
Oral
Synthetic Heparinoid-like Agents fondaparinux
ELIQUIS PRADAXA XARELTO COUMADIN
Tier 2 ARIXTRA
HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: http://www.asco.org Guidelines for the management of anemia associated with chronic kidney disease are available at: http://www.kidney.org/professionals/kdoqi/guidelines_commentaries.cfm#guidelines SGM SGM SGM SGM
darbepoetin alfa epoetin alfa filgrastim pegfilgrastim
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS SGM eltrombopag
Tier 2 Tier 2 Tier 2 Tier 2
ARANESP PROCRIT NEUPOGEN NEULASTA
Tier 2 PROMACTA
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS † eculizumab
SOLIRIS
PLATELET AGGREGATION INHIBITORS clopidogrel dipyridamole dipyridamole ext-rel/aspirin prasugrel ticagrelor
Tier 1 Tier 2 Tier 2 Tier 2 Tier 2
PLATELET SYNTHESIS INHIBITORS anagrelide
Tier 2 AGRYLIN
LEGEND boldface † OTC PA QL SGM ST
PERSANTINE AGGRENOX EFFIENT BRILINTA
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 33
STEM CELL MOBILIZERS SGM plerixafor
Tier 2 MOZOBIL
MISCELLANEOUS cilostazol
Tier 2 PLETAL
IMMUNOLOGIC AGENTS Guidelines for the management of rheumatic diseases are available at: http://www.rheumatology.org ALLERGENIC EXTRACTS PA grass mixed pollen allergen extract PA ragweed pollen allergen extract PA timothy grass pollen allergen extract
Tier 2 ORALAIR Tier 2 RAGWITEK Tier 2 GRASTEK
BIOLOGIC DISEASE-MODIFYING AGENTS SGM adalimumab SGM etanercept SGM, ST anakinra SGM, ST certolizumab pegol SGM, ST golimumab
Tier 2 Tier 2 Tier 3 Tier 3 Tier 3
HUMIRA ENBREL KINERET CIMZIA SIMPONI
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) methotrexate hydroxychloroquine leflunomide methotrexate SGM methotrexate auto-injector
Tier 1 Tier 2 Tier 2 Tier 2 Tier 2
PLAQUENIL ARAVA RHEUMATREX RASUVO
Tier 2 Tier 2 Tier 2 Tier 2
INTRON A PEGASYS PEGINTRON SYLATRON
IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: http://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of hepatitis are available at: http://www.aasld.org Interferons SGM SGM SGM SGM
interferon alfa-2b peginterferon alfa-2a peginterferon alfa-2b peginterferon alfa-2b
Miscellaneous SGM canakinumab
Tier 2 ILARIS
IMMUNOSUPPRESSANTS Antimetabolites azathioprine azathioprine mycophenolate mofetil mycophenolate sodium delayed-rel
Tier 2 Tier 2 Tier 2 Tier 2
LEGEND boldface † OTC PA QL SGM ST
AZASAN IMURAN CELLCEPT MYFORTIC
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 34
Calcineurin Inhibitors cyclosporine cyclosporine, modified tacrolimus
Tier 2 SANDIMMUNE Tier 2 NEORAL Tier 2 PROGRAF
Rapamycin Derivatives sirolimus
Tier 2 RAPAMUNE
NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium chloride ext-rel potassium chloride liquid
Tier 1 Tier 1
VITAMINS AND MINERALS Folic Acid/Combinations folic acid folic acid/vitamin B6/vitamin B12
Tier 1 Tier 1
Prenatal Vitamins prenatal vitamins prenatal vitamins/DHA/docusate/folic acid prenatal vitamins/DHA/docusate/folic acid prenatal vitamins/DHA/docusate/folic acid prenatal vitamins/docusate/folic acid prenatal vitamins/docusate/folic acid + DHA prenatal vitamins/folic acid + pyridoxine
Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Miscellaneous cyanocobalamin inj multivitamins/fluoride drops, tabs multivitamins/fluoride/iron drops, tabs vitamin ADC/fluoride drops vitamin ADC/fluoride/iron drops ergocalciferol (D2) fluoride drops fluoride tabs
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 DRISDOL Tier 2 LURIDE Tier 2 LURIDE LOZI-TABS
CITRANATAL 90 DHA CITRANATAL DHA CITRANATAL HARMONY CITRANATAL RX CITRANATAL ASSURE CITRANATAL B-CALM
RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: http://www.aaaai.org http://www.ginasthma.com http://www.goldcopd.com http://www.nhlbi.nih.gov The Allergy Report and guidelines for allergy-related conditions are available at: http://www.aaaai.org ANAPHYLAXIS TREATMENT AGENTS epinephrine LEGEND boldface † OTC PA QL SGM ST
Tier 2 AUVI-Q
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 35
epinephrine epinephrine
Tier 2 EPIPEN Tier 2 EPIPEN JR.
ANTICHOLINERGICS QL ipratropium soln QL tiotropium
Tier 1 Tier 2 SPIRIVA
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS QL ipratropium/albuterol, CFC-free aerosol QL umeclidinium/vilanterol QL ipratropium/albuterol soln
Tier 2 COMBIVENT RESPIMAT Tier 2 ANORO ELLIPTA Tier 3 DUONEB
ANTIHISTAMINES, LOW SEDATING levocetirizine
Tier 2 XYZAL
ANTIHISTAMINES, SEDATING clemastine 2.68 mg cyproheptadine hydroxyzine HCl
Tier 1 Tier 1 Tier 1
ANTITUSSIVES Clinical practice guidelines are available at: http://journal.publications.chestnet.org/article.aspx?articleID=1084267 benzonatate ANTITUSSIVE COMBINATIONS Opioid codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin liquid codeine/guaifenesin/pseudoephedrine codeine/promethazine codeine/promethazine/phenylephrine hydrocodone/homatropine
Tier 2 TESSALON
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Non-opioid dextromethorphan/brompheniramine/pseudoephedrine dextromethorphan/promethazine
Tier 1 Tier 1
BETA AGONISTS Inhalants Short Acting QL albuterol soln QL albuterol sulfate, CFC-free aerosol
Tier 1 Tier 2 PROAIR HFA
Long Acting QL QL QL QL
Tier 2 Tier 2 Tier 2 Tier 2
LEGEND boldface † OTC PA QL SGM ST
formoterol inhalation caps formoterol inhalation soln indacaterol salmeterol xinafoate
FORADIL PERFOROMIST ARCAPTA NEOHALER SEREVENT
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 36
Oral Agents albuterol terbutaline albuterol ext-rel
Tier 1 Tier 1 Tier 2 VOSPIRE ER
CYSTIC FIBROSIS SGM dornase alfa SGM tobramycin inhalation soln
Tier 2 PULMOZYME Tier 2 TOBI
LEUKOTRIENE RECEPTOR ANTAGONISTS zafirlukast montelukast
Tier 1 Tier 3 SINGULAIR
MAST CELL STABILIZERS QL cromolyn soln
Tier 1
NASAL ANTIHISTAMINES QL azelastine spray QL azelastine spray QL olopatadine spray
Tier 1 Tier 3 ASTEPRO Tier 3 PATANASE
NASAL STEROIDS QL flunisolide spray QL fluticasone spray ST, QL mometasone spray QL triamcinolone acetonide spray
Tier 1 Tier 1 Tier 2 NASONEX Tier 3 NASACORT AQ
PHOSPHODIESTERASE-4 INHIBITORS roflumilast
Tier 2 DALIRESP
STEROID/BETA AGONIST COMBINATIONS QL fluticasone/salmeterol QL fluticasone/salmeterol, CFC-free aerosol QL mometasone/formoterol
Tier 2 ADVAIR Tier 2 ADVAIR HFA Tier 2 DULERA
STEROID INHALANTS QL beclomethasone, CFC-free aerosol QL budesonide QL fluticasone QL fluticasone, CFC-free aerosol QL mometasone QL budesonide inh susp
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3
XANTHINES theophylline ext-rel tabs
Tier 1
MISCELLANEOUS ipratropium spray omalizumab
Tier 2 ATROVENT spray Tier 2 XOLAIR
LEGEND boldface † OTC PA QL SGM ST
QVAR PULMICORT FLEXHALER FLOVENT DISKUS FLOVENT HFA ASMANEX PULMICORT RESPULES
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 37
TOPICAL DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: http://www.aad.org/education-and-quality-care/clinical-guidelines Oral isotretinoin
Tier 1
erythromycin gel 2% erythromycin soln sulfacetamide/sulfur crm, gel, lotion, pads tretinoin adapalene adapalene/benzoyl peroxide clindamycin/benzoyl peroxide clindamycin/benzoyl peroxide tazarotene tretinoin tretinoin gel microsphere benzoyl peroxide clindamycin gel, lotion, soln clindamycin/benzoyl peroxide erythromycin/benzoyl peroxide sulfacetamide lotion 10% tretinoin
Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Topical
Actinic Keratosis fluorouracil soln 5%, soln 2% imiquimod ingenol mebutate fluorouracil
AVITA DIFFERIN EPIDUO ACANYA BENZACLIN TAZORAC ATRALIN RETIN-A MICRO BENZAC AC CLEOCIN T DUAC BENZAMYCIN KLARON RETIN-A
Tier 1 Tier 2 ZYCLARA Tier 2 PICATO
Antibiotics gentamicin mupirocin silver sulfadiazine
Tier 1 Tier 2 BACTROBAN Tier 2 SILVADENE
clotrimazole econazole ketoconazole nystatin efinaconazole luliconazole naftifine ciclopirox
Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 3
Antifungals
LEGEND boldface † OTC PA QL SGM ST
JUBLIA LUZU NAFTIN LOPROX
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 38
Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: http://www.aad.org Injectable SGM, ST
ustekinumab
Tier 3 STELARA
acitretin methoxsalen oral
Tier 3 SORIATANE Tier 3 OXSORALEN-ULTRA
calcipotriene calcipotriene
Tier 2 SORILUX Tier 3 DOVONEX
Oral
Topical
Antiseborrheics ketoconazole shampoo 2% selenium sulfide shampoo 2.5%
Tier 2 NIZORAL SHAMPOO Tier 2 SELSUN
Corticosteroids Low Potency fluocinolone acetonide soln 0.01% hydrocortisone crm 2.5% hydrocortisone lotion 1% alclometasone crm, oint 0.05% desonide crm, lotion, oint 0.05%
Tier 1 Tier 1 Tier 1 Tier 2 ACLOVATE Tier 2 DESOWEN
Medium Potency betamethasone valerate crm, lotion, oint 0.1% fluocinolone acetonide crm, oint 0.025% triamcinolone acetonide crm, lotion 0.025% triamcinolone acetonide crm, lotion, oint 0.1% clocortolone crm 0.1% desoximetasone oint 0.05% fluticasone propionate oint 0.005% hydrocortisone butyrate lotion 0.1% hydrocortisone butyrate oint, soln 0.1% hydrocortisone valerate oint 0.2% mometasone oint 0.1% desoximetasone crm 0.05% fluticasone propionate crm, lotion 0.05% hydrocortisone butyrate crm 0.1% hydrocortisone butyrate crm 0.1% hydrocortisone valerate crm 0.2% mometasone crm, lotion 0.1%
Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
High Potency betamethasone dipropionate crm, lotion, oint 0.05% diflorasone diacetate crm 0.05% fluocinonide crm, gel, oint, soln 0.05% triamcinolone acetonide crm 0.5%
Tier 1 Tier 1 Tier 1 Tier 1
LEGEND boldface † OTC PA QL SGM ST
CLODERM TOPICORT LP CUTIVATE LOCOID LOCOID WESTCORT ELOCON TOPICORT LP CUTIVATE LOCOID LOCOID LIPOCREAM WESTCORT ELOCON
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 39
desoximetasone oint 0.25%, gel 0.05% betamethasone dipropionate augmented crm 0.05% betamethasone dipropionate augmented lotion 0.05% desoximetasone crm 0.25% Very High Potency clobetasol propionate foam 0.05% diflorasone diacetate oint 0.05% betamethasone dipropionate augmented gel, oint 0.05% clobetasol propionate crm, gel, oint 0.05% clobetasol propionate lotion, shampoo 0.05% halobetasol propionate crm, oint 0.05% clobetasol propionate soln 0.05%
Tier 2 Tier 3 Tier 3 Tier 3
TOPICORT DIPROLENE AF DIPROLENE TOPICORT
Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3
DIPROLENE TEMOVATE CLOBEX ULTRAVATE TEMOVATE
Emollients ammonium lactate 12%
Tier 2 LAC-HYDRIN
Immunomodulators Guidelines for the treatment of atopic dermatitis are available at: http://www.aad.org/education/clinical-guidelines tacrolimus pimecrolimus
Tier 1 Tier 2 ELIDEL
Local Analgesics lidocaine patch
Tier 2 LIDODERM
Local Anesthetics lidocaine/prilocaine
Tier 1
Rosacea metronidazole gel 0.75% sulfacetamide/sulfur azelaic acid gel doxycycline monohydrate ivermectin metronidazole crm 0.75% metronidazole gel 1% metronidazole lotion 0.75%
Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3
FINACEA ORACEA SOOLANTRA METROCREAM METROGEL METROLOTION
Scabicides and Pediculicides permethrin 5% malathion
Tier 1 Tier 2 OVIDE
Miscellaneous Skin and Mucous Membrane imiquimod penciclovir podofilox
Tier 2 ALDARA Tier 2 DENAVIR Tier 2 CONDYLOX
LEGEND boldface † OTC PA QL SGM ST
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 40
MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous
Tier 1
Protectants - Mouth/Throat benzyl alcohol/carbomer 941/glycerin soy phospholipid/glycerol dioleate
Tier 2 MUGARD Tier 2 EPISIL
Steroids - Mouth/Throat triamcinolone paste
Tier 1
OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: http://one.aao.org Antiallergics azelastine cromolyn sodium olopatadine olopatadine
Tier 1 Tier 1 Tier 2 PATADAY Tier 2 PATANOL
Anti-infectives bacitracin erythromycin gentamicin levofloxacin polymyxin B/bacitracin sulfacetamide oint 10% besifloxacin moxifloxacin moxifloxacin ciprofloxacin neomycin/polymyxin B/gramicidin ofloxacin polymyxin B/trimethoprim sulfacetamide soln 10% tobramycin
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
BESIVANCE MOXEZA VIGAMOX CILOXAN NEOSPORIN OCUFLOX POLYTRIM BLEPH-10 TOBREX
Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/bacitracin/hydrocortisone oint neomycin/polymyxin B/hydrocortisone susp sulfacetamide/prednisolone phosphate 10%/0.25% tobramycin/dexamethasone oint 0.3%/0.1% tobramycin/dexamethasone susp 0.3%/0.05% tobramycin/loteprednol neomycin/polymyxin B/dexamethasone tobramycin/dexamethasone susp 0.3%/0.1%
Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3
TOBRADEX OINTMENT TOBRADEX ST ZYLET MAXITROL TOBRADEX SUSPENSION
LEGEND boldface † OTC PA QL SGM ST
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 41
Anti-inflammatories Nonsteroidal bromfenac sodium diclofenac sodium bromfenac sodium 0.07% ketorolac
Tier 1 Tier 1 Tier 2 PROLENSA Tier 3 ACULAR
Steroidal dexamethasone sodium phosphate difluprednate loteprednol 0.2% loteprednol 0.5% fluorometholone prednisolone acetate 1% prednisolone phosphate 1%
Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3
trifluridine
Tier 2 VIROPTIC
DUREZOL ALREX LOTEMAX FML PRED FORTE
Antivirals Beta-blockers Nonselective timolol hemihydrate levobunolol metipranolol timolol maleate timolol maleate gel
Tier 2 Tier 3 Tier 3 Tier 3 Tier 3
BETIMOL BETAGAN OPTIPRANOLOL TIMOPTIC TIMOPTIC-XE
Selective betaxolol
Tier 2 BETOPTIC S
Carbonic Anhydrase Inhibitors Topical brinzolamide dorzolamide
Tier 2 AZOPT Tier 3 TRUSOPT
Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate/preservative-free dorzolamide/timolol maleate
Tier 2 COSOPT PF Tier 3 COSOPT
Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations brinzolamide/brimonidine
Tier 2 SIMBRINZA
Immunomodulators cyclosporine, emulsion
Tier 2 RESTASIS
Prostaglandins travoprost tafluprost travoprost latanoprost
Tier 1 Tier 2 ZIOPTAN Tier 2 TRAVATAN Z Tier 3 XALATAN
LEGEND boldface † OTC PA QL SGM ST
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 42
Sympathomimetics brimonidine 0.2% brimonidine 0.1% brimonidine 0.15%
Tier 1 Tier 2 ALPHAGAN P Tier 2 ALPHAGAN P
Sympathomimetic/Beta-blocker Combinations brimonidine/timolol
Tier 2 COMBIGAN
OTIC Clinical practice guidelines for the treatment of otitis media are available at: http://www.aap.org Anti-infectives acetic acid acetic acid/aluminum acetate ofloxacin otic
Tier 1 Tier 1 Tier 1
Anti-infective/Anti-inflammatory Combinations ciprofloxacin/dexamethasone neomycin/polymyxin B/hydrocortisone
Tier 2 CIPRODEX Tier 2 CORTISPORIN OTIC
LEGEND boldface † OTC PA QL SGM ST
indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name. Coverage determined under the Medical Benefit Over the Counter Prior Authorization Quantity Limit Specialty Guideline Management Step Therapy 43
WEBSITES Agency for Healthcare Research and Quality http://www.ahrq.gov Alzheimer's Association http://www.alz.org American Academy of Allergy, Asthma and Immunology http://www.aaaai.org American Academy of Child & Adolescent Psychiatry http://www.aacap.org American Academy of Dermatology http://www.aad.org American Academy of Neurology http://www.aan.com American Academy of Ophthalmology http://www.aao.org American Academy of Pediatrics http://www.aap.org American Association for the Study of Liver Disease http://www.aasld.org American Association of Clinical Endocrinologists http://www.aace.com American Association of Diabetes Educators http://www.diabeteseducator.org American Cancer Society http://www.cancer.org American College of Allergy, Asthma and Immunology http://www.acaai.org American College of Cardiology http://www.acc.org American College of Chest Physicians http://www.chestnet.org
American Congress of Obstetricians and Gynecologists http://www.acog.org American Diabetes Association http://www.diabetes.org American Gastroenterological Association http://www.gastro.org American Headache Society Committee for Headache Education http://www.achenet.org American Heart Association http://www.myamericanheart.org American Lung Association http://www.lung.org American Medical Association http://www.ama-assn.org American Psychiatric Association http://www.psych.org American Society of Anesthesiologists http://www.asahq.org American Society of Clinical Oncology http://www.asco.org American Society of Interventional Pain Physicians http://www.asipp.org American Urological Association http://www.auanet.org Centers for Disease Control and Prevention http://www.cdc.gov Centers for Disease Control and Prevention Guideline topics: AIDS http://www.cdc.gov/hiv/default.html
American College of Gastroenterology http://gi.org
Centers for Disease Control and Prevention Guideline topics: Sexually Transmitted Diseases http://www.cdc.gov/std/treatment/default.htm
American College of Physicians http://www.acponline.org
CVS/caremark™ http://www.caremark.com
American College of Rheumatology http://www.rheumatology.org
The Food and Drug Administration http://www.fda.gov
44
Global Initiative for Asthma http://www.ginasthma.com
National Foundation for Infectious Diseases http://www.nfid.org
Infectious Diseases Society of America http://www.idsociety.org
National Guideline Clearinghouse http://www.guideline.gov
Institute for Safe Medication Practices http://www.ismp.org
National Heart, Lung and Blood Institute http://www.nhlbi.nih.gov
Johns Hopkins AIDS Service http://www.thebody.com/content/art12096.html
National Institutes of Health http://www.nih.gov
Juvenile Diabetes Research Foundation International http://jdrf.org
National Kidney Foundation http://www.kidney.org
MedWatch http://www.fda.gov/Safety/MedWatch/default.htm
National Osteoporosis Foundation http://www.nof.org
National Agricultural Library http://www.nal.usda.gov
North American Menopause Society http://www.menopause.org
National Cancer Institute http://www.cancer.gov/cancertopics
United States Department of Health and Human Services http://www.hhs.gov
National Comprehensive Cancer Network http://www.nccn.org
World Health Organization http://www.who.int
45
INDEX A abacavir tabs, 10 abacavir/dolutegravir/lamivudine, 10 abacavir/lamivudine, 10 ABILIFY injection, 20 ABSTRAL, 8 acamprosate calcium, 23 ACANYA, 38 acarbose, 24 ACCUPRIL, 13 ACCURETIC, 14 ACEON, 13 acetazolamide, 17 acetazolamide ext-rel, 17 acetic acid, 43 acetic acid/aluminum acetate, 43 acitretin, 39 ACLOVATE, 39 ACTIGALL, 30 ACTONEL, 25 ACTOPLUS MET, 24 ACULAR, 42 acyclovir caps, tabs, 11 ADALAT CC, 16 adalimumab, 34 adapalene, 38 adapalene/benzoyl peroxide, 38 ADCIRCA, 18 ADVAIR, 37 ADVAIR HFA, 37 AFINITOR, 13 AGGRENOX, 33 AGRYLIN, 33 albendazole, 11 ALBENZA, 11 albuterol, 37 albuterol ext-rel, 37 albuterol soln, 36 albuterol sulfate, CFC-free aerosol, 36 alclometasone crm, oint 0.05%, 39 ALDACTAZIDE, 17 ALDACTONE, 14 ALDARA, 40 alendronate, 25 alfuzosin ext-rel, 32 ALINIA, 11 aliskiren, 17 aliskiren/amlodipine, 17 aliskiren/amlodipine/hydrochlorothiazide, 17 aliskiren/hydrochlorothiazide, 17 ALKERAN, 12 allopurinol, 7 alosetron, 31 ALPHAGAN P, 43 alprazolam, 18 ALREX, 42 ALTACE, 13 altretamine, 12 amantadine, 20 AMARYL, 25 AMBIEN, 22 AMBIEN CR, 22
ambrisentan, 18 amiloride, 17 amiloride/hydrochlorothiazide, 17 amiodarone, 15 amitriptyline, 20 amlodipine, 16 amlodipine/atorvastatin, 16 amlodipine/benazepril, 13 amlodipine/olmesartan, 14 amlodipine/telmisartan, 14 amlodipine/valsartan, 14 amlodipine/valsartan/hydrochlorothiazide, 14 ammonium lactate 12%, 40 amoxicillin, 9 amoxicillin/clavulanate, 9 amoxicillin/clavulanate ext-rel, 9 amphetamine/dextroamphetamine mixed salts, 21 amphetamine/dextroamphetamine mixed salts ext-rel, 21 ampicillin, 9 AMTURNIDE, 17 ANAFRANIL, 18 anagrelide, 33 anakinra, 34 ANAPROX, 7 anastrozole, 12 ANDRODERM, 23 ANORO ELLIPTA, 36 ANTABUSE, 23 ANTARA, 15 ANTIVERT, 29 ANUSOL-HC, 32 apixaban, 33 APRISO, 30 ARALEN, 10 ARANESP, 33 ARAVA, 34 ARCAPTA NEOHALER, 36 ARICEPT, 19 ARIMIDEX, 12 aripiprazole, 21 aripiprazole inj, 20 ARIXTRA, 33 armodafinil, 23 AROMASIN, 12 artemether/lumefantrine, 10 ASMANEX, 37 ASTEPRO, 37 atazanavir, 10 atazanavir/cobicistat, 10 ATELVIA, 25 atenolol, 16 atenolol/chlorthalidone, 16 ATIVAN, 18 atomoxetine, 21 atorvastatin, 15 atovaquone/proguanil, 10 ATRALIN, 38 ATRIPLA, 10 ATROVENT spray, 37 AUBAGIO, 22 AUGMENTIN, 9 AUVI-Q, 35 AVELOX, 9 46
AVINZA, 8 AVITA, 38 AVODART, 32 AXIRON, 23 AYGESTIN, 29 AZASAN, 34 azathioprine, 34 azelaic acid gel, 40 azelastine, 41 azelastine spray, 37 AZILECT, 20 azithromycin, 9 AZOPT, 42 AZOR, 14 AZULFIDINE, 30 AZULFIDINE EN-TABS, 30
B bacitracin, 41 baclofen, 22 BACTROBAN, 38 balsalazide, 30 BARACLUDE, 11 BD insulin syringes and needles, 25 beclomethasone, CFC-free aerosol, 37 benazepril, 13 benazepril/hydrochlorothiazide, 14 BENICAR, 14 BENICAR HCT, 14 BENTYL, 30 BENZAC AC, 38 BENZACLIN, 38 BENZAMYCIN, 38 benzonatate, 36 benzoyl peroxide, 38 benztropine, 20 benzyl alcohol/carbomer 941/glycerin, 41 besifloxacin, 41 BESIVANCE, 41 BETAGAN, 42 betamethasone dipropionate augmented crm 0.05%, 40 betamethasone dipropionate augmented gel, oint 0.05%, 40 betamethasone dipropionate augmented lotion 0.05%, 40 betamethasone dipropionate crm, lotion, oint 0.05%, 39 betamethasone valerate crm, lotion, oint 0.1%, 39 BETAPACE, 15 BETAPACE AF, 15 betaxolol, 42 bethanechol, 32 BETIMOL, 42 BETOPTIC S, 42 bexarotene caps, 13 BEYAZ, 26 BIAXIN, 9 BIAXIN XL, 9 bicalutamide, 12 BIDIL, 18 bismuth/metronidazole/tetracycline, 32 bisoprolol, 16 bisoprolol/hydrochlorothiazide, 16 BLEPH-10, 41 blood glucose continuous monitoring receivers, sensors, transmitters, 25 blood glucose monitoring kits, test strips, 25 BONIVA, 25 bosentan, 18
BOSULIF, 12 bosutinib, 12 BREVICON, 26 BRILINTA, 33 brimonidine 0.1%, 43 brimonidine 0.15%, 43 brimonidine 0.2%, 43 brimonidine/timolol, 43 BRINTELLIX, 19 brinzolamide, 42 brinzolamide/brimonidine, 42 BRISDELLE, 23 bromfenac sodium, 42 bromfenac sodium 0.07%, 42 bromocriptine, 20 budesonide, 37 budesonide delayed-rel caps, 30 budesonide ext-rel, 30 budesonide inh susp, 37 bumetanide, 17 buprenorphine transdermal, 7 buprenorphine/naloxone sublingual tabs, 23 bupropion, 20 bupropion ext-rel, 20, 23 buspirone, 18 busulfan, 12 butalbital/acetaminophen/caffeine tabs, 8 butalbital/aspirin/caffeine, 8 BUTRANS, 7 BYSTOLIC, 16
C cabergoline, 29 CADUET, 16 CALAN SR, 16 calcipotriene, 39 calcitonin-salmon, 25 calcitriol (1,25-D3), 28 calcium acetate, 28 calcium acetate tabs, 28 CAMPRAL, 23 canagliflozin, 25 canagliflozin/metformin, 25 canakinumab, 34 CANASA, 30 candesartan, 14 candesartan/hydrochlorothiazide, 14 capecitabine, 12 captopril, 13 captopril/hydrochlorothiazide, 14 CARAFATE, 32 carbamazepine, 18 carbamazepine ext-rel, 19 CARBATROL, 19 carbidopa/levodopa, 20 carbidopa/levodopa ext-rel, 20 carbidopa/levodopa orally disintegrating tabs, 20 carbidopa/levodopa/entacapone, 20 CARDURA, 14 carisoprodol, 22 CARNITOR, 29 carvedilol, 16 carvedilol phosphate ext-rel, 16 CASODEX, 12 CATAPRES, 14 CATAPRES-TTS, 14 47
CEENU, 12 cefadroxil, 9 cefdinir, 9 cefixime, 9 cefprozil, 9 CEFTIN, 9 cefuroxime axetil, 9 CELEBREX, 7 celecoxib, 7 CELEXA, 19 CELLCEPT, 34 cephalexin, 9 certolizumab pegol, 34 cetrorelix, 28 CETROTIDE, 28 cevimeline, 31 CHANTIX, 23 chlorambucil, 12 chlordiazepoxide/clidinium, 30 chloroquine, 10 chlorpromazine, 21 chlorthalidone, 17 chlorzoxazone, 22 cholestyramine, 15 choriogonadotropin alfa, 28 chorionic gonadotropin - Novarel, 28 ciclopirox, 38 cilostazol, 34 CILOXAN, 41 cimetidine, 30 CIMZIA, 34 CIPRO, 9 CIPRODEX, 43 ciprofloxacin, 9, 41 ciprofloxacin ext-rel, 9 ciprofloxacin/dexamethasone, 43 citalopram, 19 CITRANATAL 90 DHA, 35 CITRANATAL ASSURE, 35 CITRANATAL B-CALM, 35 CITRANATAL DHA, 35 CITRANATAL HARMONY, 35 CITRANATAL RX, 35 clarithromycin, 9 clarithromycin ext-rel, 9 clemastine 2.68 mg, 36 CLEOCIN, 11, 32 CLEOCIN T, 38 CLIMARA, 27 clindamycin, 11 clindamycin crm, 32 clindamycin gel, lotion, soln, 38 clindamycin/benzoyl peroxide, 38 CLINORIL, 7 clobetasol propionate crm, gel, oint 0.05%, 40 clobetasol propionate foam 0.05%, 40 clobetasol propionate lotion, shampoo 0.05%, 40 clobetasol propionate soln 0.05%, 40 CLOBEX, 40 clocortolone crm 0.1%, 39 CLODERM, 39 CLOMID, 28 clomiphene, 28 clomipramine, 18 clonazepam tabs, 18 clonidine, 14
clonidine transdermal, 14 clopidogrel, 33 clotrimazole, 38 clotrimazole troches, 9 clozapine, 21 CLOZARIL, 21 COARTEM, 10 codeine/acetaminophen, 8 codeine/chlorpheniramine/pseudoephedrine, 36 codeine/guaifenesin liquid, 36 codeine/guaifenesin/pseudoephedrine, 36 codeine/promethazine, 36 codeine/promethazine/phenylephrine, 36 colchicine, 7 COLCRYS, 7 colesevelam, 15 COLESTID, 15 colestipol, 15 COMBIGAN, 43 COMBIVENT RESPIMAT, 36 COMBIVIR, 10 COMPLERA, 10 COMTAN, 20 CONCERTA, 21 CONDYLOX, 40 conjugated estrogens/bazedoxifene, 27 COPAXONE, 22 COPEGUS, 11 CORDARONE, 15 COREG, 16 COREG CR, 16 CORGARD, 16 CORTEF, 28 CORTIFOAM, 30 CORTISPORIN OTIC, 43 COSOPT, 42 COSOPT PF, 42 COUMADIN, 33 COZAAR, 14 CREON, 31 CRESTOR, 15 CRINONE, 29 cromolyn sodium, 41 cromolyn soln, 37 CUTIVATE, 39 cyanocobalamin inj, 35 CYCLESSA, 26 cyclobenzaprine, 22 cyclophosphamide caps, 12 CYCLOPHOSPHAMIDE caps, 12 cyclosporine, 35 cyclosporine, emulsion, 42 cyclosporine, modified, 35 cyproheptadine, 36 CYTOMEL, 29 CYTOTEC, 31
D D.H.E. 45, 22 dabigatran etexilate, 33 DALIRESP, 37 dalteparin, 33 danazol, 27 DANTRIUM, 23 dantrolene, 23 dapsone, 11 48
darbepoetin alfa, 33 darunavir, 10 darunavir/cobicistat, 10 dasatinib, 12 DAYPRO, 7 DAYTRANA, 21 DDAVP, 29 delavirdine, 10 DEMADEX, 17 DENAVIR, 40 DEPAKENE, 19 DEPAKOTE, 19 DEPAKOTE ER, 19 DEPO-PROVERA, 27 desipramine, 20 desmopressin spray, tabs, 29 desogestrel/EE, 26 desogestrel/EE 0.15/30, 26 desonide crm, lotion, oint 0.05%, 39 DESOWEN, 39 desoximetasone crm 0.05%, 39 desoximetasone crm 0.25%, 40 desoximetasone oint 0.05%, 39 desoximetasone oint 0.25%, gel 0.05%, 40 desvenlafaxine ext-rel, 20 DETROL, 32 dexamethasone, 28 dexamethasone sodium phosphate, 42 DEXCOM G4, 25 DEXEDRINE SPANSULE, 21 DEXILANT, 31 dexlansoprazole delayed-rel, 31 dexmethylphenidate, 21 dexmethylphenidate ext-rel, 21 dextroamphetamine, 21 dextroamphetamine ext-rel, 21 dextromethorphan/brompheniramine/pseudoephedrine, 36 dextromethorphan/promethazine, 36 DIAMOX SEQUELS, 17 DIASTAT, 19 diazepam, 18 diazepam rectal gel, 19 DICLEGIS, 29 diclofenac sodium, 42 diclofenac sodium delayed-rel, 7 diclofenac sodium delayed-rel/misoprostol, 7 diclofenac sodium gel, 7 diclofenac sodium soln, 7 dicloxacillin, 9 dicyclomine, 30 didanosine delayed-rel, 10 DIFFERIN, 38 DIFICID, 9 diflorasone diacetate crm 0.05%, 39 diflorasone diacetate oint 0.05%, 40 DIFLUCAN, 9 diflunisal, 7 difluprednate, 42 digoxin, 16 digoxin ped elixir, 16 dihydroergotamine inj, 22 dihydroergotamine spray, 22 DILANTIN, 19 DILANTIN INFATABS, 19 DILAUDID, 8 diltiazem ext-rel, 16
dimethyl fumarate delayed-rel, 22 DIPENTUM, 30 diphenoxylate/atropine, 29 DIPROLENE, 40 DIPROLENE AF, 40 dipyridamole, 33 dipyridamole ext-rel/aspirin, 33 disopyramide, 15 disopyramide ext-rel, 15 disulfiram, 23 DITROPAN XL, 32 divalproex sodium delayed-rel, 19 divalproex sodium ext-rel, 19 DIVIGEL, 27 dofetilide, 15 dolutegravir, 10 donepezil, 19 dornase alfa, 37 dorzolamide, 42 dorzolamide/timolol maleate, 42 dorzolamide/timolol maleate/preservative-free, 42 DOVONEX, 39 doxazosin, 14 doxepin, 20, 22 doxercalciferol, 28 doxycycline hyclate, 9 doxycycline hyclate 20 mg, 9 doxycycline monohydrate, 40 doxylamine/pyridoxine delayed-rel, 29 DRISDOL, 35 dronabinol, 29 drospirenone/EE 3/20, 26 drospirenone/EE 3/30, 26 drospirenone/EE/levomefolate 3/20 and levomefolate, 26 drospirenone/EE/levomefolate 3/30 and levomefolate, 26 DUAC, 38 DUAVEE, 27 DUETACT, 24 DULERA, 37 duloxetine delayed-rel, 20 DUONEB, 36 DURAGESIC, 8 DUREZOL, 42 dutasteride, 32 DYAZIDE, 17
E E.E.S., 9 econazole, 38 eculizumab, 33 EDURANT, 10 EE/norethindrone acetate - Jinteli, 27 efavirenz, 10 efavirenz/emtricitabine/tenofovir, 10 EFFEXOR XR, 20 EFFIENT, 33 efinaconazole, 38 eletriptan, 22 ELIDEL, 40 ELIQUIS, 33 ELOCON, 39 eltrombopag, 33 elvitegravir/cobicistat/emtricitabine/tenofovir, 10 emtricitabine, 10 emtricitabine/rilpivirine/tenofovir, 10 emtricitabine/tenofovir, 10 49
EMTRIVA, 10 enalapril, 13 enalapril/hydrochlorothiazide, 14 ENBREL, 34 ENDOMETRIN, 29 enfuvirtide, 10 enoxaparin, 33 entacapone, 20 entecavir, 11 EPIDUO, 38 epinephrine, 35, 36 EPIPEN, 36 EPIPEN JR., 36 EPISIL, 41 EPIVIR, 10 EPIVIR-HBV, 11 eplerenone, 14 epoetin alfa, 33 epoprostenol sodium, 18 eprosartan, 14 EPZICOM, 10 ergocalciferol (D2), 35 erlotinib, 13 erythromycin, 41 erythromycin delayed-rel, 9 erythromycin ethylsuccinate, 9 erythromycin gel 2%, 38 erythromycin soln, 38 erythromycin stearate, 9 erythromycin/benzoyl peroxide, 38 erythromycin/sulfisoxazole, 9 escitalopram, 19 ESGIC, 8 esomeprazole delayed-rel, 31 ESTRACE, 27 estradiol, 27 estradiol vaginal crm, 27 estradiol vaginal tabs, 27 estradiol valerate and dienogest/estradiol valerate, 26 estradiol/norethindrone, 27 estrogens, conjugated, 27 estrogens, conjugated crm, 27 estrogens, conjugated/medroxyprogesterone, 27 estropipate, 27 eszopiclone, 22 etanercept, 34 ethambutol, 11 ethosuximide, 19 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 26 ethynodiol diacetate/EE 1/50 - Zovia 1/50, 26 etodolac, 7 etonogestrel/EE ring, 27 etoposide, 13 etravirine, 10 EVAMIST, 27 everolimus, 13 EVISTA, 29 EVOTAZ, 10 EVOXAC, 31 EVZIO, 23 EXALGO, 8 EXELON, 19 EXELON PATCH, 19 exemestane, 12 exenatide ext-rel, 24 ezetimibe, 15
ezetimibe/simvastatin, 15
F famciclovir, 11 famotidine, 30 FAMVIR, 11 FARXIGA, 25 febuxostat, 7 felodipine ext-rel, 16 FEMARA, 12 fenofibrate, 15 fenofibric acid delayed-rel, 15 fentanyl citrate buccal, 7 fentanyl sublingual spray, 7 fentanyl sublingual tabs, 8 fentanyl transdermal, 8 fentanyl transmucosal lozenge, 7 FENTORA, 7 fidaxomicin, 9 filgrastim, 33 FINACEA, 40 finasteride, 32 fingolimod, 22 FIORINAL, 8 FLAGYL, 11 flecainide, 15 FLOLAN, 18 FLOMAX, 32 FLOVENT DISKUS, 37 FLOVENT HFA, 37 fluconazole, 9 fludrocortisone, 28 flunisolide spray, 37 fluocinolone acetonide crm, oint 0.025%, 39 fluocinolone acetonide soln 0.01%, 39 fluocinonide crm, gel, oint, soln 0.05%, 39 fluoride drops, 35 fluoride tabs, 35 fluorometholone, 42 fluorouracil, 38 fluorouracil soln 5%, soln 2%, 38 fluoxetine, 19 FLUOXETINE 60 mg, 19 fluphenazine, 21 flutamide, 12 fluticasone, 37 fluticasone propionate crm, lotion 0.05%, 39 fluticasone propionate oint 0.005%, 39 fluticasone spray, 37 fluticasone, CFC-free aerosol, 37 fluticasone/salmeterol, 37 fluticasone/salmeterol, CFC-free aerosol, 37 fluvastatin, 15 fluvoxamine, 18 FML, 42 FOCALIN, 21 FOCALIN XR, 21 folic acid, 35 folic acid/vitamin B6/vitamin B12, 35 FOLLISTIM AQ, 28 follitropin beta, 28 fondaparinux, 33 FORADIL, 36 formoterol inhalation caps, 36 formoterol inhalation soln, 36 FORTEO, 25 50
FOSAMAX, 25 fosinopril, 13 fosinopril/hydrochlorothiazide, 14 FRAGMIN, 33 FURADANTIN, 11 furosemide, 17 FUZEON, 10
G gabapentin, 19 gabapentin ext-rel, 23 GABITRIL, 18 galantamine, 19 galantamine ext-rel, 19 ganirelix, 28 GELNIQUE, 32 gemfibrozil, 15 gentamicin, 38, 41 GEODON, 21 GILENYA, 22 glatiramer, 22 GLEEVEC, 13 glimepiride, 25 glipizide, 25 glipizide ext-rel, 25 glipizide/metformin, 24 GLUCAGEN HYPOKIT, 28 GLUCAGON EMERGENCY KIT, 28 glucagon, human recombinant, 28 GLUCOPHAGE, 24 GLUCOPHAGE XR, 24 GLUCOTROL, 25 GLUCOTROL XL, 25 glyburide, 25 golimumab, 34 GOLYTELY, 31 goserelin acetate, 12 GRALISE, 23 granisetron, 29 granisetron transdermal, 29 grass mixed pollen allergen extract, 34 GRASTEK, 34 griseofulvin ultramicrosize, 9 GRIS-PEG, 9 guanfacine, 14 guanfacine ext-rel, 21
H halobetasol propionate crm, oint 0.05%, 40 haloperidol, 21 HECTOROL, 28 HEXALEN, 12 HUMATROPE, 28 HUMIRA, 34 HUMULIN R U-500, 24 HYCAMTIN caps, 13 hydralazine, 18 HYDREA, 13 hydrochlorothiazide, 17 hydrocodone/acetaminophen, 8 hydrocodone/homatropine, 36 hydrocortisone, 28 hydrocortisone acetate foam, 30 hydrocortisone acetate/pramoxine foam, 32 hydrocortisone butyrate crm 0.1%, 39 hydrocortisone butyrate lotion 0.1%, 39 hydrocortisone butyrate oint, soln 0.1%, 39
hydrocortisone crm, 32 hydrocortisone crm 2.5%, 39 hydrocortisone enema, 30 hydrocortisone lotion 1%, 39 hydrocortisone valerate crm 0.2%, 39 hydrocortisone valerate oint 0.2%, 39 hydromorphone, 8 hydromorphone ext-rel, 8 hydroxychloroquine, 34 hydroxyurea, 13 hydroxyzine HCl, 36 hyoscyamine sulfate, 30 hyoscyamine sulfate ext-rel, 30 hyoscyamine sulfate ext-rel caps, 30 hyoscyamine sulfate orally disintegrating tabs, 30 HYZAAR, 14
I ibandronate, 25 ibuprofen, 7 ICLUSIG, 13 ILARIS, 34 iloprost, 18 imatinib mesylate, 13 IMDUR, 17 imipramine HCl, 20 imiquimod, 38, 40 IMITREX, 22 IMURAN, 34 indacaterol, 36 indapamide, 17 INDERAL LA, 16 ingenol mebutate, 38 INSPRA, 14 insulin aspart, 24 insulin aspart protamine 70%/insulin aspart 30%, 24 insulin detemir, 24 insulin glargine, 24 insulin human, 24 insulin isophane human, 24 insulin isophane human 70%/regular 30%, 24 insulin syringes, needles, 25 INTELENCE, 10 interferon alfa-2b, 34 interferon beta-1b, 22 INTRON A, 34 ipratropium soln, 36 ipratropium spray, 37 ipratropium/albuterol soln, 36 ipratropium/albuterol, CFC-free aerosol, 36 irbesartan, 14 irbesartan/hydrochlorothiazide, 14 ISENTRESS, 10 isoniazid, 11 ISORDIL, 17 isosorbide dinitrate ext-rel tabs, 17 isosorbide dinitrate oral, 17 isosorbide dinitrate/hydralazine, 18 isosorbide mononitrate, 17 isosorbide mononitrate ext-rel, 17 isotretinoin, 38 itraconazole, 9 ivermectin, 11, 40
J JANUMET, 24 JANUMET XR, 24 51
JANUVIA, 24 JARDIANCE, 25 JENTADUETO, 24 JUBLIA, 38
K KADIAN, 8 KALETRA, 10 KEFLEX, 9 KEPPRA, 19 KEPPRA XR, 19 ketoconazole, 38 ketoconazole shampoo 2%, 39 ketorolac, 42 KHEDEZLA, 20 KINERET, 34 KLARON, 38 KLONOPIN, 18 KUVAN, 28
L labetalol, 16 LAC-HYDRIN, 40 lacosamide, 18 lactulose, 31 LAMICTAL, 19 LAMICTAL ODT, 19 LAMICTAL XR, 18 LAMISIL, 10 lamivudine, 10, 11 lamivudine/zidovudine, 10 lamotrigine, 19 lamotrigine ext-rel, 18 lamotrigine orally disintegrating tabs, 19 lancets, 25 LANCETS, 25 LANOXIN, 16 lansoprazole + amoxicillin + clarithromycin, 32 lansoprazole delayed-rel, 31 LANTUS, 24 lapatinib, 13 LASIX, 17 latanoprost, 42 LATUDA, 20 leflunomide, 34 lenalidomide, 12 LETAIRIS, 18 letrozole, 12 LEUKERAN, 12 leuprolide acetate, 12 LEVAQUIN, 9 LEVBID, 30 LEVEMIR, 24 levetiracetam, 19 levetiracetam ext-rel, 19 levobunolol, 42 levocarnitine, 29 levocetirizine, 36 levofloxacin, 9, 41 levonorgestrel releasing IUD, 27 levonorgestrel/EE - Trivora, 26 levonorgestrel/EE 0.1/20 - Lessina, 26 levonorgestrel/EE 0.1/20 and EE 10, 26 levonorgestrel/EE 0.15/30, 26 levonorgestrel/EE 0.15/30 - Levora, 26 levonorgestrel/EE 0.15/30 and EE 10, 26 levothyroxine, 29
levothyroxine - Levoxyl, 29 LEVSIN, 30 LEXAPRO, 19 LIALDA, 30 lidocaine patch, 40 lidocaine viscous, 41 lidocaine/prilocaine, 40 LIDODERM, 40 linaclotide, 30 linagliptin, 24 linagliptin/metformin, 24 LINZESS, 30 liothyronine, 29 LIPOFEN, 15 liraglutide, 24 lisdexamfetamine, 21 lisinopril, 13 lisinopril/hydrochlorothiazide, 14 lithium carbonate, 22 lithium carbonate ext-rel tabs 300 mg, 22 lithium carbonate ext-rel tabs 450 mg, 22 LITHOBID, 22 LO LOESTRIN FE, 25 LOCOID, 39 LOCOID LIPOCREAM, 39 LOESTRIN 1.5/30, 26 LOESTRIN 1/20, 26 LOESTRIN FE 1.5/30, 26 LOESTRIN FE 1/20, 26 LOFIBRA, 15 LOMOTIL, 29 lomustine, 12 loperamide, 29 LOPID, 15 lopinavir/ritonavir, 10 LOPRESSOR, 16 LOPRESSOR HCT, 16 LOPROX, 38 lorazepam, 18 losartan, 14 losartan/hydrochlorothiazide, 14 LOSEASONIQUE, 26 LOTEMAX, 42 LOTENSIN, 13 LOTENSIN HCT, 14 loteprednol 0.2%, 42 loteprednol 0.5%, 42 LOTREL, 13 LOTRONEX, 31 lovastatin, 15 LOVAZA, 16 LOVENOX, 33 lubiprostone, 30 luliconazole, 38 LUPRON DEPOT, 12 lurasidone, 20 LURIDE, 35 LURIDE LOZI-TABS, 35 LUZU, 38 LYRICA, 21 LYSODREN, 13
M MACROBID, 11 MACRODANTIN, 11 MALARONE, 10 52
malathion, 40 MARINOL, 29 MATULANE, 13 MAVIK, 13 MAXALT, 22 MAXITROL, 41 MAXZIDE, 17 meclizine, 29 MEDROL, 28 medroxyprogesterone acetate, 29 medroxyprogesterone acetate 150 mg/mL, 27 mefloquine, 10 MEGACE, 12 MEGACE ES, 29 megestrol acetate, 12 megestrol acetate susp, 29 meloxicam, 7 melphalan, 12 memantine, 19 memantine ext-rel, 19 mercaptopurine, 12 mesalamine delayed-rel tabs, 30 mesalamine ext-rel caps, 30 mesalamine rectal susp, 30 mesalamine supp, 30 MESTINON, 23 MESTINON TIMESPAN, 23 METAGLIP, 24 metaxalone, 23 metformin, 24 metformin ext-rel, 24 methadone, 7 methazolamide, 17 methimazole, 29 methocarbamol, 23 methotrexate, 12, 34 methotrexate auto-injector, 34 methoxsalen oral, 39 methyldopa, 18 METHYLIN, 21 methylnaltrexone, 31 methylphenidate, 21 methylphenidate ext-rel, 21 methylphenidate ext-rel 10 mg, 21 methylphenidate ext-rel susp, 21 methylphenidate transdermal, 21 methylprednisolone, 28 metipranolol, 42 metoclopramide, 30 metolazone, 17 metoprolol succinate ext-rel, 16 metoprolol tartrate, 16 metoprolol/hydrochlorothiazide, 16 METROCREAM, 40 METROGEL, 40 METROGEL-VAGINAL, 32 METROLOTION, 40 metronidazole, 11, 32 metronidazole crm 0.75%, 40 metronidazole gel 0.75%, 40 metronidazole gel 1%, 40 metronidazole lotion 0.75%, 40 MEVACOR, 15 MIACALCIN, 25 MICARDIS, 14 MICARDIS HCT, 14
midodrine, 18 MIGRANAL, 22 milnacipran, 21 MINASTRIN 24 FE, 26 MINIVELLE, 27 MINOCIN, 9 minocycline, 9 mirabegron ext-rel, 32 MIRALAX, 31 MIRAPEX, 20 MIRAPEX ER, 20 MIRCETTE, 26 MIRENA, 27 mirtazapine, 20 misoprostol, 31 mitotane, 13 MOBIC, 7 MODICON, 26 mometasone, 37 mometasone crm, lotion 0.1%, 39 mometasone oint 0.1%, 39 mometasone spray, 37 mometasone/formoterol, 37 montelukast, 37 morphine, 7 morphine ext-rel, 8 morphine supp, 7 MOVANTIK, 31 MOVIPREP, 31 MOXEZA, 41 moxifloxacin, 9, 41 MOZOBIL, 34 MS CONTIN, 8 MUGARD, 41 multivitamins/fluoride drops, tabs, 35 multivitamins/fluoride/iron drops, tabs, 35 mupirocin, 38 MYAMBUTOL, 11 mycophenolate mofetil, 34 mycophenolate sodium delayed-rel, 34 MYFORTIC, 34 MYLERAN, 12 MYRBETRIQ, 32 MYSOLINE, 19
N nabumetone, 7 nadolol, 16 naftifine, 38 NAFTIN, 38 naloxegol, 31 naloxone, 23 naltrexone, 23 NAMENDA, 19 NAMENDA XR, 19 NAPROSYN, 7 naproxen, 7 naproxen sodium, 7 naratriptan, 22 NARDIL, 19 NASACORT AQ, 37 NASONEX, 37 NATAZIA, 26 nateglinide, 25 nebivolol, 16 neomycin/polymyxin B/bacitracin/hydrocortisone oint, 41 53
neomycin/polymyxin B/dexamethasone, 41 neomycin/polymyxin B/gramicidin, 41 neomycin/polymyxin B/hydrocortisone, 43 neomycin/polymyxin B/hydrocortisone susp, 41 NEORAL, 35 NEOSPORIN, 41 NEULASTA, 33 NEUPOGEN, 33 NEUPRO, 20 NEURONTIN, 19 nevirapine, 10 nevirapine ext-rel, 10 NEXAVAR, 13 NEXIUM, 31 niacin ext-rel, 15 niacin ext-rel/simvastatin, 15 NIASPAN, 15 nifedipine ext-rel, 16 nitazoxanide, 11 NITRO-DUR, 17 nitrofurantoin ext-rel, 11 nitrofurantoin macrocrystals, 11 nitrofurantoin susp, 11 nitroglycerin lingual spray, 17 nitroglycerin sublingual, 17 nitroglycerin transdermal, 17 NITROLINGUAL, 17 NITROSTAT, 17 NIZORAL SHAMPOO, 39 NORCO, 8 NORDITROPIN, 28 norelgestromin/EE, 27 norethindrone, 26, 27 norethindrone acetate, 29 norethindrone acetate/EE 1.5/30, 26 norethindrone acetate/EE 1.5/30 and iron, 26 norethindrone acetate/EE 1/10 and EE 10 and iron, 25 norethindrone acetate/EE 1/20, 26 norethindrone acetate/EE 1/20 and iron, 26 norethindrone acetate/EE 1/20 and iron - Lomedia 24 Fe, 26 norethindrone acetate/EE 1/20 and iron chewable, 26 norethindrone/EE, 26 norethindrone/EE 0.5/35, 26 norethindrone/EE 1/35, 26 norethindrone/ME 1/50, 26 norgestimate/EE, 26 norgestimate/EE 0.25/35, 26 norgestrel/EE 0.3/30 - Low-Ogestrel, 26 NORINYL 1+35, 26 NORINYL 1+50, 26 NORPACE, 15 NORPACE CR, 15 NORPRAMIN, 20 NOR-QD, 26 nortriptyline, 20 NORVIR, 10 NOVOLIN 70/30, 24 NOVOLIN N, 24 NOVOLIN R, 24 NOVOLOG, 24 NOVOLOG MIX 70/30, 24 NUCYNTA, 8 NUCYNTA ER, 8 NULYTELY, 31 NUVARING, 27 NUVIGIL, 23
nystatin, 9, 38
O OCUFLOX, 41 ofloxacin, 41 ofloxacin otic, 43 olanzapine, 21 olmesartan, 14 olmesartan/amlodipine/hydrochlorothiazide, 14 olmesartan/hydrochlorothiazide, 14 olopatadine, 41 olopatadine spray, 37 olsalazine, 30 omalizumab, 37 omega-3 acid ethyl esters, 16 omeprazole delayed-rel, 31 omeprazole/sodium bicarbonate caps, 31 ondansetron, 30 ONETOUCH ULTRA kits and test strips, 25 ONETOUCH VERIO kits and test strips, 25 OPANA ER, 8 OPTIPRANOLOL, 42 ORACEA, 40 ORALAIR, 34 orphenadrine/aspirin/caffeine, 22 ORTHO EVRA, 27 ORTHO MICRONOR, 27 ORTHO TRI-CYCLEN, 26 ORTHO TRI-CYCLEN LO, 26 ORTHO-CEPT, 26 ORTHO-CYCLEN, 26 ORTHO-NOVUM 1/35, 26 ORTHO-NOVUM 7/7/7, 26 oseltamivir, 11 ospemifene, 29 OSPHENA, 29 OVIDE, 40 OVIDREL, 28 oxaprozin, 7 oxazepam, 18 oxcarbazepine, 19 OXSORALEN-ULTRA, 39 oxybutynin, 32 oxybutynin ext-rel, 32 oxybutynin gel, 32 oxycodone caps, tabs 5 mg, 7 oxycodone concentrate 20 mg/mL, 7 oxycodone ext-rel, 8 oxycodone tabs 15 mg, 30 mg, soln 5 mg/5 mL, 8 oxycodone/acetaminophen 5/325, 8 OXYCONTIN, 8 oxymorphone ext-rel, 8
P PAMELOR, 20 pancrelipase, 31 pancrelipase delayed-rel, 31 pantoprazole delayed-rel, 31 PARAFON FORTE DSC, 22 PARCOPA, 20 paricalcitol, 28 PARLODEL, 20 PARNATE, 19 paroxetine HCl, 19 paroxetine HCl ext-rel, 19 paroxetine mesylate, 23 PATADAY, 41 54
PATANASE, 37 PATANOL, 41 PAXIL, 19 PAXIL CR, 19 pazopanib, 13 peg 3350/electrolytes, 31 PEGASYS, 34 pegfilgrastim, 33 peginterferon alfa-2a, 34 peginterferon alfa-2b, 34 peginterferon beta-1a, 22 PEGINTRON, 34 penciclovir, 40 penicillin VK, 9 PENTASA, 30 PEPCID, 30 PERCOCET, 8 PERFOROMIST, 36 perindopril, 13 permethrin 5%, 40 perphenazine, 21 PERSANTINE, 33 phenazopyridine, 32 phenelzine, 19 phenobarbital, 18 phenytoin, 19 phenytoin sodium extended, 19 PHOSLO, 28 PHOSLYRA, 28 PICATO, 38 pilocarpine tabs, 31 pimecrolimus, 40 pindolol, 16 pioglitazone, 24 pioglitazone/glimepiride, 24 pioglitazone/metformin, 24 PLAQUENIL, 34 plerixafor, 34 PLETAL, 34 podofilox, 40 polyethylene glycol 3350, 31 polymyxin B/bacitracin, 41 polymyxin B/trimethoprim, 41 POLYTRIM, 41 pomalidomide, 12 POMALYST, 12 ponatinib, 13 potassium chloride ext-rel, 35 potassium chloride liquid, 35 potassium citrate ext-rel, 32 PRADAXA, 33 pramipexole, 20 pramipexole ext-rel, 20 pramlintide, 24 PRANDIN, 25 prasugrel, 33 PRAVACHOL, 15 pravastatin, 15 PRECOSE, 24 PRED FORTE, 42 prednisolone acetate 1%, 42 prednisolone phosphate 1%, 42 prednisolone sodium phosphate, 28 prednisolone sodium phosphate 5 mg/5 mL, 28 prednisolone syrup, 28 prednisone, 28
pregabalin, 21 PRELONE, 28 PREMARIN, 27 PREMARIN crm, 27 PREMPHASE, 27 PREMPRO, 27 prenatal vitamins, 35 prenatal vitamins/DHA/docusate/folic acid, 35 prenatal vitamins/docusate/folic acid, 35 prenatal vitamins/docusate/folic acid + DHA, 35 prenatal vitamins/folic acid + pyridoxine, 35 PREVPAC, 32 PREZCOBIX, 10 PREZISTA, 10 PRILOSEC, 31 primidone, 19 PRISTIQ, 20 PROAIR HFA, 36 probenecid, 7 procarbazine, 13 PROCARDIA XL, 16 prochlorperazine, 29 PROCRIT, 33 PROCTOFOAM-HC, 32 progesterone gel, 29 progesterone vaginal inserts, 29 progesterone, micronized, 29 PROGRAF, 35 PROLENSA, 42 PROMACTA, 33 promethazine, 29 PROMETRIUM, 29 propafenone, 15 propafenone ext-rel, 15 propranolol, 16 propranolol ext-rel, 16 propylthiouracil, 29 PROSCAR, 32 PROVERA, 29 PROZAC, 19 PULMICORT FLEXHALER, 37 PULMICORT RESPULES, 37 PULMOZYME, 37 PYLERA, 32 pyrazinamide, 11 PYRIDIUM, 32 pyridostigmine, 23 pyridostigmine ext-rel, 23
Q QUESTRAN/QUESTRAN LIGHT, 15 quetiapine, 21 quetiapine ext-rel, 20 QUILLIVANT XR, 21 quinapril, 13 quinapril/hydrochlorothiazide, 14 QVAR, 37
R ragweed pollen allergen extract, 34 RAGWITEK, 34 raloxifene, 29 raltegravir, 10 ramipril, 13 RANEXA, 18 ranitidine, 30 ranolazine ext-rel, 18 55
RAPAFLO, 32 RAPAMUNE, 35 rasagiline mesylate, 20 RASUVO, 34 RAZADYNE, 19 RAZADYNE ER, 19 REBETOL, 11 REBIF, 22 REGLAN, 30 RELENZA, 11 RELPAX, 22 REMERON, 20 REMODULIN, 18 RENVELA, 28 repaglinide, 25 REQUIP, 20 REQUIP XL, 20 RESCRIPTOR, 10 RESTASIS, 42 RESTORIL, 21 RETIN-A, 38 RETIN-A MICRO, 38 RETROVIR, 10 REVATIO, 18 REVIA, 23 REVLIMID, 12 REYATAZ, 10 RHEUMATREX, 34 ribavirin caps, 11 ribavirin oral soln, 11 ribavirin tabs, 11 RIFADIN, 11 rifampin, 11 rifaximin, 11 rilpivirine, 10 risedronate, 25 risedronate delayed-rel, 25 RISPERDAL, 21 RISPERDAL CONSTA, 20 risperidone, 21 risperidone long-acting injection, 20 RITALIN, 21 RITALIN LA, 21 ritonavir, 10 rivaroxaban, 33 rivastigmine, 19 rivastigmine transdermal, 19 rizatriptan, 22 ROBAXIN, 23 ROCALTROL, 28 roflumilast, 37 ropinirole, 20 ropinirole ext-rel, 20 rosuvastatin, 15 rotigotine transdermal, 20 ROWASA, 30 ROXICODONE, 8 RYTHMOL, 15 RYTHMOL SR, 15
S SAFYRAL, 26 SALAGEN, 31 salmeterol xinafoate, 36 SANCUSO, 29 SANDIMMUNE, 35
sapropterin, 28 SAVELLA, 21 SEASONIQUE, 26 selegiline, 20 selegiline orally disintegrating tabs, 20 selenium sulfide shampoo 2.5%, 39 SELSUN, 39 SEREVENT, 36 SEROQUEL, 21 SEROQUEL XR, 20 sertraline, 20 sevelamer carbonate, 28 sildenafil, 18 SILENOR, 22 silodosin, 32 SILVADENE, 38 silver sulfadiazine, 38 SIMBRINZA, 42 SIMCOR, 15 SIMPONI, 34 simvastatin, 15 SINEMET, 20 SINEMET CR, 20 SINGULAIR, 37 sirolimus, 35 sitagliptin phosphate, 24 sitagliptin/metformin, 24 sitagliptin/metformin ext-rel, 24 SIVEXTRO, 11 SKELAXIN, 23 sodium sulfate/potassium sulfate/magnesium sulfate, 31 solifenacin succinate, 32 SOLIRIS, 33 somatropin, 28 SOOLANTRA, 40 sorafenib, 13 SORIATANE, 39 SORILUX, 39 sotalol, 15 soy phospholipid/glycerol dioleate, 41 SPIRIVA, 36 spironolactone, 14 spironolactone/hydrochlorothiazide, 17 SPORANOX, 9 SPRYCEL, 12 STALEVO, 20 stavudine, 10 STELARA, 39 STRATTERA, 21 STRIBILD, 10 STROMECTOL, 11 SUBSYS, 7 SUCLEAR, 31 sucralfate, 32 sucroferric oxyhydroxide, 28 sulfacetamide lotion 10%, 38 sulfacetamide oint 10%, 41 sulfacetamide soln 10%, 41 sulfacetamide/prednisolone phosphate 10%/0.25%, 41 sulfacetamide/sulfur, 40 sulfacetamide/sulfur crm, gel, lotion, pads, 38 sulfamethoxazole/trimethoprim, 11 sulfamethoxazole/trimethoprim DS, 11 sulfasalazine, 30 sulfasalazine delayed-rel, 30 sulindac, 7 56
sumatriptan, 22 sumatriptan inj, 22 sumatriptan nasal spray, 22 sumatriptan/naproxen sodium, 22 SUMAVEL DOSEPRO, 22 sunitinib, 13 SUPRAX, 9 SUPREP, 31 SUSTIVA, 10 SUTENT, 13 SYLATRON, 34 SYMLINPEN, 24 SYNTHROID, 29
T TABLOID, 12 tacrolimus, 35, 40 tadalafil, 18 tafluprost, 42 TAMBOCOR, 15 TAMIFLU, 11 tamoxifen, 12 tamsulosin, 32 TAPAZOLE, 29 tapentadol, 8 tapentadol ext-rel, 8 TARCEVA, 13 TARGRETIN caps, 13 TARKA, 13 tazarotene, 38 TAZORAC, 38 TECFIDERA, 22 tedizolid, 11 TEGRETOL, 18 TEGRETOL-XR, 19 TEKAMLO, 17 TEKTURNA, 17 TEKTURNA HCT, 17 telmisartan, 14 telmisartan/hydrochlorothiazide, 14 temazepam, 21 TEMODAR, 12 TEMOVATE, 40 temozolomide, 12 TENEX, 14 tenofovir, 10 TENORETIC, 16 TENORMIN, 16 TERAZOL 3, 32 TERAZOL 7, 32 terazosin, 14 terbinafine tabs, 10 terbutaline, 37 terconazole, 32 teriparatide, 25 TESSALON, 36 testosterone cypionate, 23 testosterone enanthate, 23 testosterone gel, 23 testosterone soln, 23 testosterone transdermal, 23 tetrabenazine, 21 tetracycline, 9 thalidomide, 12 THALOMID, 12 theophylline ext-rel tabs, 37
thioguanine, 12 thiothixene, 21 tiagabine, 18 TIAZAC, 16 ticagrelor, 33 TIGAN, 30 TIKOSYN, 15 timolol hemihydrate, 42 timolol maleate, 42 timolol maleate gel, 42 TIMOPTIC, 42 TIMOPTIC-XE, 42 timothy grass pollen allergen extract, 34 TINDAMAX, 11 tinidazole, 11 tiotropium, 36 TIVICAY, 10 tizanidine, 23 TOBI, 37 TOBRADEX OINTMENT, 41 TOBRADEX ST, 41 TOBRADEX SUSPENSION, 41 tobramycin, 41 tobramycin inhalation soln, 37 tobramycin/dexamethasone oint 0.3%/0.1%, 41 tobramycin/dexamethasone susp 0.3%/0.05%, 41 tobramycin/dexamethasone susp 0.3%/0.1%, 41 tobramycin/loteprednol, 41 TOBREX, 41 TOFRANIL, 20 tolterodine, 32 tolterodine ext-rel, 32 TOPAMAX, 19 TOPICORT, 40 TOPICORT LP, 39 topiramate, 19 topotecan caps, 13 TOPROL-XL, 16 torsemide, 17 TOUJEO, 24 TRACLEER, 18 TRADJENTA, 24 tramadol, 8 tramadol ext-rel, 7 trandolapril, 13 trandolapril/verapamil ext-rel, 13 tranylcypromine, 19 TRAVATAN Z, 42 travoprost, 42 trazodone, 20 TRELSTAR, 12 treprostinil, 18 tretinoin, 38 tretinoin caps, 13 tretinoin gel microsphere, 38 TREXALL, 12 TREXIMET, 22 triamcinolone acetonide crm 0.5%, 39 triamcinolone acetonide crm, lotion 0.025%, 39 triamcinolone acetonide crm, lotion, oint 0.1%, 39 triamcinolone acetonide spray, 37 triamcinolone paste, 41 triamterene/hydrochlorothiazide, 17 TRIBENZOR, 14 trifluoperazine, 21 trifluridine, 42 57
trihexyphenidyl, 20 TRILEPTAL, 19 TRILIPIX, 15 trimethobenzamide, 30 trimethoprim, 11 TRI-NORINYL, 26 triptorelin pamoate, 12 TRIUMEQ, 10 trospium, 32 trospium ext-rel, 32 TRULICITY, 24 TRUSOPT, 42 TRUVADA, 10 TYKERB, 13 TYLENOL w/CODEINE, 8 TYVASO, 18
voriconazole, 9 vorinostat, 13 vortioxetine, 19 VOSPIRE ER, 37 VOTRIENT, 13 VYTORIN, 15 VYVANSE, 21
U
XALATAN, 42 XANAX, 18 XARELTO, 33 XELODA, 12 XENAZINE, 21 XIFAXAN 550 mg, 11 XIGDUO XR, 25 XOLAIR, 37 XYZAL, 36
UCERIS, 30 ULORIC, 7 ULTRAM, 8 ULTRAVATE, 40 ULTRESA, 31 umeclidinium/vilanterol, 36 URECHOLINE, 32 UROCIT-K, 32 URSO, 30 ursodiol, 30 ustekinumab, 39
V VAGIFEM, 27 valacyclovir, 11 VALCYTE, 11 valganciclovir, 11 VALIUM, 18 valproic acid, 19 valsartan, 14 valsartan/hydrochlorothiazide, 14 VANCOCIN, 11 vancomycin, 11 varenicline, 23 VASERETIC, 14 VASOTEC, 13 VELPHORO, 28 venlafaxine, 20 venlafaxine ext-rel, 20 VENTAVIS, 18 verapamil ext-rel, 16 VESICARE, 32 VFEND, 9 VIBRAMYCIN, 9 VICTOZA, 24 VIDEX EC, 10 VIGAMOX, 41 VIIBRYD, 19 vilazodone, 19 VIMPAT, 18 VIOKACE, 31 VIRAMUNE, 10 VIRAMUNE XR, 10 VIREAD, 10 VIROPTIC, 42 vitamin ADC/fluoride drops, 35 vitamin ADC/fluoride/iron drops, 35 VIVELLE-DOT, 27 VOLTAREN GEL, 7
W warfarin, 33 WELCHOL, 15 WELLBUTRIN, 20 WELLBUTRIN SR, 20 WELLBUTRIN XL, 20 WESTCORT, 39
X
Y YASMIN, 26 YAZ, 26
Z zafirlukast, 37 ZANAFLEX tabs, 23 zanamivir, 11 ZANTAC, 30 ZARONTIN, 19 ZAROXOLYN, 17 ZEBETA, 16 ZELAPAR, 20 ZEMPLAR, 28 ZENPEP, 31 ZERIT, 10 ZESTORETIC, 14 ZESTRIL, 13 ZETIA, 15 ZIAC, 16 ZIAGEN tabs, 10 zidovudine, 10 ZIOPTAN, 42 ziprasidone, 21 ZITHROMAX, 9 ZOCOR, 15 ZOFRAN, 30 ZOLADEX, 12 ZOLINZA, 13 zolmitriptan, 22 zolmitriptan nasal spray, 22 ZOLOFT, 20 zolpidem, 22 zolpidem ext-rel, 22 ZOMIG, 22 ZONEGRAN, 19 zonisamide, 19 ZOVIRAX, 11 ZUBSOLV, 23 ZYBAN, 23 ZYCLARA, 38 58
ZYLET, 41 ZYLOPRIM, 7
ZYPREXA, 21
59
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