Network Health Together® (MassHealth) and Network Health Forward® (Commonwealth Care) Pharmacy Benefit and Preferred Drug List for MassHealth and Commonwealth Care Plan Type I (October 1, 2011 for co-payment changes; October 3, 2011 for Preferred Drug List changes)
Introduction ................................................................................................................................... 7 Preferred Drug List .................................................................................................................. 7 Our pharmacy benefit ............................................................................................................. 7 Obtaining prescription coverage ............................................................................................ 8 Requests for prior authorization...................................................................................... 8 Requests for step care agents ........................................................................................... 8 Requests for nonpreferred drugs ..................................................................................... 9 Exclusions ................................................................................................................................. 9 Generic substitution ........................................................................................................ 10 New-to-market drugs ...................................................................................................... 10 Quantity limits ................................................................................................................. 10 Coverage limits ................................................................................................................ 10 Specialty pharmacy program ............................................................................................... 11 Central nervous system agents ................................................................................................... 13 Analgesic and anti-inflammatory agents ............................................................................. 13 Nonsteriodal and anti-inflammatory agents ................................................................. 13 COX-2 inhibitor agents ................................................................................................... 13 Disease-modifying antirheumatic agents (DMARDs) .................................................. 13 Anti-inflammatory, anti-arthritic agents, miscellaneous ............................................. 13 Anti-inflammatory, tumor necrosis factor inhibitor .................................................... 14 Migraine agents ............................................................................................................... 14 Opiate agonists ................................................................................................................. 15 Opiate antagonists ........................................................................................................... 15 Opiate agonists/antagonists ............................................................................................ 15 Miscellaneous analgesics ................................................................................................. 15 Miscellaneous opiate agents ............................................................................................ 16 Alzheimer’s agents ................................................................................................................ 16 Anticonvulsant agents ........................................................................................................... 16 Antiparkinsonian agents ....................................................................................................... 17 Muscle relaxant agents .......................................................................................................... 17 Skeletal muscle agents ..................................................................................................... 17 Neuromuscular blocking agents ..................................................................................... 18 Amyotrophic lateral sclerosis agents ............................................................................. 18 Parasympathomimetic (cholinergic) agents ........................................................................ 18 Psychotherapeutic agents...................................................................................................... 18 Tricyclic antidepressant agents ...................................................................................... 18 S.S.R.I. agents .................................................................................................................. 18 M.A.O. inhibitor agents .................................................................................................. 19
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Miscellaneous antidepressant agents ............................................................................. 19 Antimanic agents ............................................................................................................. 19 Psychotherapeutic combination agents ......................................................................... 19 Benzodiazepines ............................................................................................................... 19 Antipsychotic agents........................................................................................................ 19 Miscellaneous anxiolytics, sedatives, and hypnotics..................................................... 20 Fibromyalgia agents ........................................................................................................ 20 Systemic stimulant agents ..................................................................................................... 20 CNS stimulants ................................................................................................................ 20 Non-stimulant ADHD agents ................................................................................................ 21 Cardiovascular/blood agents ...................................................................................................... 21 Anti-arrhythmic agents ......................................................................................................... 21 Antihypertensive agents ........................................................................................................ 21 Direct rennin inhibitor .................................................................................................... 21 Peripherally acting adrenergic agents ........................................................................... 21 Beta-adrenergic antagonist agents ................................................................................. 22 Combination alpha-beta antagonist agents ................................................................... 22 Angiotensin converting enzyme inhibitor agents ......................................................... 22 Angiotensin receptor blocker agents ............................................................................. 22 Calcium channel blocking agents ................................................................................... 22 Centrally acting adrenergic agents ................................................................................ 23 Combination antihypertensive agents ........................................................................... 23 Antihypertensive, pulmonary arterial ........................................................................... 23 Drugs for pheochromocytoma ........................................................................................ 24 Potassium-sparing diuretics ........................................................................................... 24 Selective aldosterone antagonist..................................................................................... 24 Loop diuretics .................................................................................................................. 24 Thiazide and related diuretics ........................................................................................ 24 Alpha antagonist agents .................................................................................................. 24 Direct vasodilator agents ................................................................................................ 24 Antiyperlipidemic combination agents ................................................................................ 25 Antiplatelet agents ................................................................................................................. 25 Antiplatelet combination agents........................................................................................... 25 Hematological agents ............................................................................................................ 25 Antifibrinolytic agents .................................................................................................... 25 Coagulants and anticoagulants ...................................................................................... 25 Antihyperlipidemic agents .................................................................................................... 25 Colony stimulating factors .............................................................................................. 26 Thrombopoietin agonists ................................................................................................ 26 Cardiac glycoside agents ....................................................................................................... 26 Hemorheologic agents ........................................................................................................... 26 Nitrate agents ......................................................................................................................... 26 Anti-anginal and anti-ischemic agents, non-hemodynamic ............................................... 26 Gastrointestinal agents................................................................................................................ 26 Antidiarrheal agents.............................................................................................................. 26 Selective 5-HT3 receptor antagonist .............................................................................. 26
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Anti-emetic agents ................................................................................................................. 26 Antimuscarinic/antispasmodic agents ................................................................................. 27 Anti-ulcer agents.................................................................................................................... 27 Proton pump inhibitors......................................................................................................... 27 Bowel evacuant agents .......................................................................................................... 28 Digestive enzymes .................................................................................................................. 28 Gallstone solubilizing agents ................................................................................................ 28 Gastrointestinal stimulant agents ........................................................................................ 28 H2 antagonist agents ............................................................................................................. 28 Laxative agents ...................................................................................................................... 28 Ulcer eradication agents ....................................................................................................... 28 Ulcerative colitis/crohns’ agents........................................................................................... 28 Anti-infective agents .................................................................................................................... 29 Amebicides ............................................................................................................................. 29 Antihelmintic agents.............................................................................................................. 29 Antibiotic agents .................................................................................................................... 29 Aminoglycosides .............................................................................................................. 29 Cephalosporins ................................................................................................................ 29 Ketolides ........................................................................................................................... 29 Macrolide antibiotic agents ............................................................................................ 29 Miscellaneous antibiotic agents ...................................................................................... 30 Penicillins ......................................................................................................................... 30 Quinolones ........................................................................................................................ 30 Sulfonamides .................................................................................................................... 30 Tetracyclines .................................................................................................................... 31 Antifungal agents ................................................................................................................... 31 Antimalarial agents ............................................................................................................... 31 Antiprotozoal agents, miscellaneous .................................................................................... 31 Antituberculosis agents ......................................................................................................... 31 Antiviral agents...................................................................................................................... 31 Hepatitis C agents ............................................................................................................ 32 HIV antiviral agents .............................................................................................................. 32 Antiviral agents, monoclonal antibodies ............................................................................. 33 Leprostatic agents.................................................................................................................. 33 Peridontal collagenase inhibitors ......................................................................................... 33 Antineoplastic and immunosuppressant agents ....................................................................... 33 Antineoplastic agents ............................................................................................................ 33 Immunomodulator injectable agents ................................................................................... 35 Immunosuppressant agents .................................................................................................. 35 Miscellaneous injectable agents ........................................................................................... 35 Multiple sclerosis agents ....................................................................................................... 35 Immune globulin agents ........................................................................................................ 36 Respiratory/EENT agents ........................................................................................................... 36 Antihistamine agents ............................................................................................................. 36 Sedating antihistamine agents ........................................................................................ 36 Nonsedating antihistamine agents ................................................................................. 36
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Nasal antihistamine ......................................................................................................... 36 Antihistamine/decongestant combination agents ............................................................... 36 Antihistamine/decongestant agents................................................................................ 36 Antitussive agents .................................................................................................................. 37 Non-narcotic antitussive agents ..................................................................................... 37 Narcotic antitussive agents ............................................................................................. 37 Bronchodilating agents ......................................................................................................... 37 Inhaled anticholinergic agents ....................................................................................... 37 Inhaled sympathomimetic (adrenergic) agents ............................................................ 37 Oral sympathomimetic (adrenergic) agents.................................................................. 38 Expectorant agents ................................................................................................................ 38 Mucolytic agents .................................................................................................................... 38 EENT preparations ............................................................................................................... 38 Carbonic anhydrase inhibitor agents ............................................................................ 38 Local anesthetic agents ................................................................................................... 38 Ophthalmic antibiotic agents ......................................................................................... 38 Opthalmic anti-inflammatory agents ............................................................................ 39 Opthalmic antiviral agents ............................................................................................. 39 Opthalmic beta blockers ................................................................................................. 39 Opthalmic miotic agents ................................................................................................. 40 Opthalmic mydriatic agents ........................................................................................... 40 Opthalmic sulfonamide agents ....................................................................................... 40 Opthalmic anti-allergic agents ....................................................................................... 40 Opthalmic prostaglandin agents .................................................................................... 40 Opthalmic miscellaneous agents .................................................................................... 41 Otic anti-infective agents ................................................................................................ 41 Inhaled anti-inflammatory agents ....................................................................................... 41 Inhaled adrenal corticosteroid agents ........................................................................... 41 Nasal inhaled corticosteroid agents ............................................................................... 41 Mast cell stabilizer ........................................................................................................... 41 Leukotriene receptor antagonists ........................................................................................ 41 Miscellaneous EENT agents ................................................................................................. 42 Miscellaneous respiratory aids ............................................................................................. 42 Respiratory smooth muscle relaxant agents ....................................................................... 42 Diabetic and thyroid agents ........................................................................................................ 42 Diabetic agents ....................................................................................................................... 42 Sulfonylureas ................................................................................................................... 42 Nonsulfonylureas ............................................................................................................. 42 Combination diabetic agents .......................................................................................... 43 Insulin agents ......................................................................................................................... 43 Miscellaneous injectable diabetic agents ............................................................................. 43 Thyroid agents ....................................................................................................................... 43 Antithyroid agents ................................................................................................................. 43 Diabetic supplies .................................................................................................................... 43 Blood glucose testing strips ............................................................................................. 44 Endocrine and metabolic agents ................................................................................................ 44
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Oral adrenocorticosteroid agents......................................................................................... 44 Androgen agents .................................................................................................................... 44 Blood glucose meters ....................................................................................................... 44 Bisphosphonate agents .......................................................................................................... 45 Miscellaneous agents for osteoporosis ................................................................................. 45 Hormone and contraceptive agents ........................................................................................... 45 Estrogen agents ...................................................................................................................... 45 Estrogen agonist-antagonists ................................................................................................ 45 Human growth hormones ..................................................................................................... 46 Growth hormone receptor antagonist ................................................................................. 46 Somatostatin analogs ............................................................................................................. 46 Oral contraceptive agents ..................................................................................................... 46 Monophasic oral contraceptives..................................................................................... 46 Biphasic oral contraceptives ........................................................................................... 47 Triphasic oral contraceptives ......................................................................................... 47 Extended-cycle oral contraceptives ............................................................................... 47 Progestin-only agents ...................................................................................................... 47 Contraceptive agents, other .................................................................................................. 48 Oxytocic agents ...................................................................................................................... 48 Pituitary agents ...................................................................................................................... 48 Progestin agents ..................................................................................................................... 48 Genitourinary agents .................................................................................................................. 48 Urinary anti-infective agents ................................................................................................ 48 Urinary pH modifiers ............................................................................................................ 48 Urinary anti-spasmodic agents............................................................................................. 48 Genitourinary smooth muscle relaxant agents ................................................................... 48 Urinary cholinergic agents ................................................................................................... 49 Benign prostatic hypertrophy agents .................................................................................. 49 Impotency agents ................................................................................................................... 49 Topical/mucous membrane agents............................................................................................. 49 Anti-acne agents .................................................................................................................... 49 Miscellaneous skin/mucous membrane agents ................................................................... 50 Topical antiseptic ............................................................................................................. 50 Pigmenting and miscellaneous agents.................................................................................. 50 Topical antibiotic agents ....................................................................................................... 51 Topical antifungal agents ...................................................................................................... 51 Vaginal antifungal agents ..................................................................................................... 51 Rectal agents .......................................................................................................................... 51 Vaginal anti-infective agents ................................................................................................ 52 Topical anti-inflammatory agents ........................................................................................ 52 Low potency topical anti-inflammatory agents ............................................................ 52 Medium potency topical anti-inflammatory agents ..................................................... 52 High potency topical anti-inflammatory agents ........................................................... 52 Very high potency topical anti-inflammatory agents ................................................... 52 Topical antipruritic and local anesthetic agents ................................................................. 53 Topical analgesics .................................................................................................................. 53
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Topical antiviral agents......................................................................................................... 53 Topical miscellaneous anti-infective agents ........................................................................ 53 Scabicide/pediculicide agents ............................................................................................... 53 Miscellaneous/unclassified agents .............................................................................................. 53 Electrolyte agents .................................................................................................................. 53 Sodium chloride ............................................................................................................... 53 Potassium agents.............................................................................................................. 54 Potassium-removing agents ............................................................................................ 54 Phosphorus agents ........................................................................................................... 54 Phosphate binders ........................................................................................................... 54 Calcimimetic .................................................................................................................... 54 Vasopressin antagonist.................................................................................................... 54 Heavy metal antagonist agents ............................................................................................. 54 Iron supplements ................................................................................................................... 55 Vitamin and fluoride agents ................................................................................................. 55 Prenatal vitamin agents .................................................................................................. 55 Fluoride agents ................................................................................................................ 55 Vitamin A ......................................................................................................................... 55 Vitamin B-complex agents .............................................................................................. 55 Vitamin B-12 .................................................................................................................... 55 Vitamin D ......................................................................................................................... 55 Vitamin K activity agents ............................................................................................... 55 Miscellaneous vitamins ................................................................................................... 55 Multivitamin agents ........................................................................................................ 55 Emergency kits ...................................................................................................................... 55 Alcohol deterrent kits ............................................................................................................ 55 Gout agents ............................................................................................................................ 56 Immunization ......................................................................................................................... 56 Tobacco cessation agents ...................................................................................................... 56 Index ............................................................................................................................................. 57
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Introduction We aim to provide high-quality, cost-effective drug therapy options. Our Preferred Drug List (PDL) is a tool to promote appropriate and cost-effective prescription outpatient drug products for your Network Health patients. Our Pharmacy and Therapeutics (P&T) Committee reviews and revises our PDL on a quarterly basis to reflect its prevailing clinical opinion. The Network Health P&T Committee evaluates PDL additions or changes using the following criteria: • Product safety profile • Product efficacy • Product comparison with alternative agents and therapeutic options • Product cost and outcomes Each quarter, we announce PDL updates via our online newsletter, Provider Update, at www.ProviderUpdate.org. For the most-recent PDL, or to use our convenient searchable PDL, please visit us online at www.network-health.org. Please note: The PDL applies to medications received at retail and specialty pharmacies, and does not apply to medications used in inpatient settings. To meet your Network Health patients’ therapeutic needs, we welcome clinicians’, pharmacists’, and ancillary medical providers’ participation in this dynamic process. Please contact our pharmacy team with any suggestions or comments by calling us at 888-257-1985.
Preferred Drug List This PDL is a list of covered and preferred drug agents for your Network Health patients. We list all products by their generic and most common proprietary (brand) names. You can access the PDL by the index, either by a drug’s generic or proprietary name, or by therapeutic drug category. We list some brand names for reference only and not to denote coverage. We consider any product not in this preferred drug listing a nonpreferred drug. We list all drugs in each category in ascending order of cost, based on your Network Health patients’ copayments. Generic drugs are in Tier 1; brand-name drugs are in Tier 2. Please note: MassHealth and Commonwealth Care Plan Type I members have a $1 to $3.65 co-payment for Tier 1 drugs and a $3.65 co-payment for Tier 2 drugs. Co-payments for covered generic medications used to treat diabetes, hypertension, and hyperlipidemia are $1 for Tier 1 drugs.
Our pharmacy benefit Our pharmacy benefit covers select over-the-counter (OTC) products, as well as prescription medications included in our PDL for all MassHealth and Commonwealth Care Plan Type I members. If your Network Health patient needs a covered OTC medication, please write a prescription for the product so your patient can obtain the medication with only a small co-payment, when applicable, or at no cost. Please see our Web site, www.network-health.org, for OTC-coverage information. You may prescribe your Network Health patients up to a 30-day supply of medication when filled at a retail pharmacy. You may prescribe up to a 60-day supply of dextroamphetamine or methylphenidate when treating attention-deficit/hyperactivity disorder (ADHD) or narcolepsy.
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We cover tobacco-cessation products listed in the PDL, including OTC nicotine gum, lozenges, and patches, with a prescription. We cover family-planning medications and products with a prescription and no co-payment. For your Network Health patients with asthma, we cover peak flow meters and spacers with a prescription and no co-payment. For your Network Health patients with diabetes, we cover testing supplies with a prescription and no copayment.
Obtaining prescription coverage Our P&T Committee reviews drug classes and selects preferred agents that don’t require prior authorization. Please see www.network-health.org for our current list of preferred agents for specific drug classes. Some drug products listed in the PDL require prior authorization.
Requests for prior authorization Please refer to our Web site at www.network-health.org for complete prior authorization information and to download appropriate forms to request authorization. Our pharmacy benefit manager, MedImpact Healthcare Systems, handles most of our prior authorizations. Please fax your MedImpact Medication Request Form (online at www.network-health.org) to MedImpact at 877-501-1059. We review requests and make initial determinations regarding prior authorizations within two business days of receiving complete medical information. Once we make a decision, we will notify you by telephone or fax within one business day. Your Network Health patients may appeal denied requests. Please see our Provider Manual for more information on the Appeals process. If your request does not meet our clinical guidelines, we may recommend another therapy. We also recognize that our PDL does not meet all medical needs, and encourage you to inquire about other therapies on a case-by-case basis. Contact phone numbers Network Health phone: 888-257-1985 Network Health pharmacy fax: 866-250-7332 MedImpact phone: 800-788-2949 MedImpact fax: 877-501-1059
Requests for step care agents We electronically review prescriptions for drug products listed in the PDL as step care agents, and we require a trial of first-line drug(s). In the absence of first-line therapy, we require prior authorization for the following drugs or classes of drugs. • •
• •
Altabax (retapamulin) requires first using mupirocin within the last 28 days. Angiotensin-II receptor blockers (ARBs), Avapro (irbesartan), Avalide (irbesartan/HCTZ), Benicar (olmesartan), Benicar HCT (olmesartan/HCTZ), Diovan (valsartan) and Diovan HCT (valsartan/HCTZ), require first using losartan or losartan/HCTZ within the last 6 months. Bystolic (nebivolol) requires first using two generic beta-blockers within the last six months. Celebrex (celecoxib) requires first using a generic nonsteroidal anti-inflammatory drug, anticoagulant, or corticosteroid within the last six months. 8
• • • • •
• • • • •
•
Coreg CR (carvedilol controlled-release) requires first using immediate-release carvedilol within the last four months. Cymbalta (duloxetine) requires first using at least two alternative medications within the last six months. Intuniv (guanfacine extended-release) requires first using immediate-release guanfacine within the last four months. Januvia (sitagliptin) and Janumet (sitagliptin/metformin) requires first using metformin or a product containing metformin within the last four months. Lialda (mesalamine delayed-release tablets) requires first using an alternative aminosalicylic acid product, such as sulfasalazine, mesalamine, balsalazide, or olsalazine, within the last six months. Retinoid topical products Differin (adapalene) and Tazorac (tazarotene) require first using tretinoin within the last six months. Singulair (montelukast) requires first using an alternative asthma medication within the last six months. Skelaxin (metaxalone) requires first using two different skeletal-muscle relaxants within the last six months. Oleptro (trazodone extended-release) requires first using immediate-release trazodone within the last six months. Triptan products Amerge (naratriptan), Axert (almotriptan), Frova (frovatriptan), Maxalt (rizatriptan), and Relpax (eletriptan) require first using generic sumatriptan and Zomig (zolmitriptan) within the last three months. Zomig (zolmitriptan) requires first using generic sumatriptan within the last three months.
Requests for nonpreferred drugs We consider any product not in the most-recent PDL to be a nonpreferred drug. However, you may request coverage for nonpreferred agents (see “requests for prior authorization” section). We will review each request based on individual patient need and will approve the request if a documented medical need exists, according to the following guidelines: • The requested drug has an FDA-approved indication. • Using different drug products in our PDL is contraindicated for the patient. • The patient has failed an appropriate trial of preferred, alternative agents. If your request does not meet our clinical guidelines, we may recommend a different therapy.
Exclusions We exclude the following medications from the pharmacy benefit: • Any drug products used for cosmetic purposes • Contraceptive implants* • Experimental and/or investigational drugs • Immunization agents, except for the influenza virus vaccine for members who are at least 18 years old, when given by a pharmacist between September 15 and March 31, at a participating pharmacy* • Infertility agents • Medical supplies* • Mifepristone (Mifeprex)* *
May be covered as a non-pharmacy benefit. 9
If you or your Network Health patients have questions about coverage, please call us at 888-257-1985.
Generic substitution When generic drugs are available, we will not cover the brand-name drug without prior authorization. This policy should not preclude or supplant any state statutes that may exist. If your Network Health patient needs a brand-name drug, please submit a prior authorization request to us. Certain drug products with complex pharmacokinetics, dosage forms, narrow therapeutic efficacy, or where blood-level maintenance is crucial are not subject to substitution. These products are: • Dilantin • Neoral oral solution • Premarin • Prograf • Synthroid We review and update this list periodically based on the clinical literature and available pharmacokineticdrug-product principles.
New-to-market drugs We review new drugs for safety and effectiveness before we add them to our PDL. If you feel a new-tomarket drug is medically necessary for a Network Health patient, please submit a prior authorization request. A clinician will review this request. If we approve the request, we will cover the drug according to our clinical guidelines. If we do not give prior authorization, your Network Health patient can appeal our decision.
Quantity limits We base specific medication quantity limits on clinical indications and practice guidelines. If you prescribe a larger quantity, we will send the pharmacist a message indicating the quantity limit. The pharmacist can adjust the quantity as necessary and resubmit the claim. If your Network Health patient needs a larger quantity, please call us at 888-257-1985 for prior authorization.
Coverage limits Please see the PDL Notes column for specific coverage limits. Coverage limits include: • PA (MedImpact) • These medications require prior authorization (PA). You may prescribe a different medication on the PDL or send a prior authorization request to our pharmacy benefit manager, MedImpact. • PA (MedImpact) If Step Care Not Met • These medications require prior authorization if we do not have a pharmacy claim for a first-line medication for your Network Health patient. You may prescribe another medication on the PDL or send a prior authorization request to our pharmacy benefit manager, MedImpact. • Quantity Limit • These medications are limited to a specific amount. If a larger amount is medically necessary, please send a prior authorization request to Network Health. • Specialty Pharmacy – Caremark • These medications are only available through our specialty pharmacy vendor, Caremark. • PA (Caremark) Specialty Pharmacy – Caremark • These medications require prior authorization and are only available through our specialty vendor, Caremark. Please send a prior authorization request to Caremark. • PA (Network Health) Specialty Pharmacy – Caremark
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•
These medications require prior authorization and are only available through our specialty pharmacy vendor, Caremark. Please send a prior authorization request to Network Health. • Preferred Product – PA (Caremark) Specialty Pharmacy – Caremark • These medications are preferred products in their drug class, require prior authorization, and are only available through our specialty pharmacy vendor, Caremark. Please send a prior authorization request to Caremark. • Excluded These medications may have some strengths or dosage forms that we do not cover.
Medicare Part D If your Network Health patients have Medicare coverage, their Medicare prescription drug coverage (Part D) plan will cover most of their prescription drugs. Even if your Network Health patients have Medicare Part D, we will cover some drugs, such as select OTC drugs. The co-payment amounts we describe earlier still apply to these covered drugs. For more information, you or your Network Health patients can call us at 888-257-1985. Your Network Health patients can also find out more about their Medicare prescription drug coverage by calling Medicare at 800-633-4227 (TTY: 877-486-2048), visiting Medicare’s Web site at www.medicare.gov, or referring to their Medicare and You Handbook.
Specialty pharmacy program We offer your Network Health patients a specialty pharmacy program provided by Caremark. Caremark reviews specialty medication prior authorizations. Please use the Caremark Enrollment Form (online at www.network-health.org) to request specialty medications. Visit www.network-health.org for information about which medications Caremark supplies. Medications Caremark provides are not available at retail pharmacies or other specialty pharmacies. In addition to providing specific specialty medications, Caremark will: • Deliver medications to your Network Health patients’ home, designated delivery address, or their clinician’s office • Provide pharmacist expertise and counseling to answer your Network Health patients and/or clinician questions and offer medication assistance • Offer education and wellness programs that provide clinicians and your Network Health patients with information, materials, and ongoing support to help patients manage their health conditions and improve medication compliance • Provide access to staff pharmacists, available to support your Network Health patients 24 hours a day, seven days a week Caremark contacts Phone: 800-237-2767 Fax: 800-323-2445 A complete list of medications Caremark provides is on the following page.
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Caremark provides the following specialty medications: Actemra1 Acthar HP1
Dacogen Dysport1
Humira1 Hyalgan
Actimmune1
Egrifta1
Hycamtin
Adcirca1 Advate Afinitor Aldurazyme1 Alferon N1 Alphanate Alphanine SD Amevive1 Ampyra1 Apokyn Aralast1 Aralast NP1 Aranesp Arcalyst1 Arzerra Avastin Avonex Bebulin VH Benefix Berinert1 Betaseron Botox1 Carimune1 Carimune NF1 Ceredase1 Cerezyme1 Cimzia1 Cinryze1 Copaxone Copegus1 Corifact Cytogam1 Cystagon1
Elaprase1 Eligard1 Enbrel1 Epogen Epoprostenol1 Euflexxa Exjade1 Extavia Fabrazyme1 Feiba VH Immuno Firmagon1 Flebogamma1 Flebogamma DIF1 Forteo1 Fusilev Fuzeon Gamastan S/D1 Gammagard Liquid1 Gammagard S/D1 Gammar-P I.V. 1 Gamunex1 Gamunex-C1 Genotropin1 Gilenya1 Glassia1 Gleevec Halaven Helixate FS Hemofil M Herceptin Hizentra1 Humate-P Humatrope1
Ilaris1 Incivek1 Increlex1 Infergen1 Intron A1 Istodax Iveegam EN1 Ixempra Jevtana Kineret1 Koate-DVI Kogenate FS Kuvan1 Letairis1 Leukine Leuprolide1 Lucentis1 Lumizyme1 Lupron1 Lupron Depot1 Lupron Depot-Ped1 Macugen1 Mitoxantrone1 Monarc M Monoclate P Mononine Mozobil1 Myobloc1 Myozyme1 Naglazyme1 Neulasta Neumega1 Neupogen
Nexavar Norditropin1,2 Norditropin Nordiflex1,2 Novantrone1 NovoSeven Nplate1 Nutropin1 Nutropin AQ1 Octagam1 Octreotide1 Oforta Omnitrope1 Orencia1 Orthovisc Panglobulin1 Panglobulin NF1 Pegasys1 PegIntron1,3 Polygam S/D1 Privigen1 Procrit Profiline SD Proleukin Prolia1 Promacta1 Proplex T Pulmozyme Rebetol1 Rebif Reclast1 Recombinate ReFacto Remicade1 Remodulin1 Revatio1 Revlimid
Rhophylac1 RiaSTAP
Tasigna Temodar
Ribavirin1
Trelstar LA1
Rituxan Sabril1 Saizen1 Samsca Sandostatin1 Sandostatin LAR1 Sensipar1 Serostim1 Simponi1 Soliris1 Somatuline Depot1 Somavert1 Sprycel Stelara1 Stimate Supartz Supprelin LA1 Sutent Sylatron Synagis1 Synvisc Synvisc-One Tarceva Targretin Tev-Tropin1,2 Thalomid Thyrogen Tikosyn TOBI Torisel Tracleer1 Treanda Trelstar Depot1
Tykerb Tysabri1 Tyvaso1 Valstar Vantas1 Vectibix Velcade Venglobulin-S1 Ventavis1 Viadur1 Victrelis1 Vidaza Visudyne1 Vivaglobulin1 Vivitrol1 Votrient VPRIV1 Wilate WinRho SDF1 Xeloda Xenazine1 Xeomin1 Xgeva1 Xiaflex1 Xolair1 Xyntha Zoladex1 Zolinza Zometa1 Zorbtive1 Zortress Zytiga
1
Medication requires prior authorization. Norditropin, Norditropin Nordiflex, and Tev-Tropin are Network Health’s preferred growth hormone agents. 3 PegIntron is Network Health’s preferred pegylated interferon. 2
Synagis Each year, from November 1 to March 31, Caremark will supply Synagis for your Network Health patients. We will review requests for Synagis, for prevention of serious respiratory disease caused by respiratory syncytial virus (RSV), and will review requests based on the most recent American Academy of Pediatrics Guidelines. If you have questions about the PDL, please call us at 888-257-1985. © 2011 Network Health.
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Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
1.00 1
Central Nervous System Agents Analgesic and Anti-inflammatory Agents Nonsteroidal Anti-inflammatory Agents
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 PA Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Choline Mag. Trisalicylate Diclofenac Potassium Diclofenac Sodium Diflunisal Etodolac Etodolac XL Fenoprofen Flurbiprofen Ibuprofen Indomethacin Indomethacin SR Ketoprofen Ketorolac Meclofenamate Mefenamic Acid Meloxicam Nabumetone Naproxen
Trilisate Cataflam Voltaren Dolobid Lodine Lodine XL Nalfon Ansaid Motrin Indocin Indocin SR Oruvail Toradol Meclomen Ponstel Mobic Relafen Naprosyn
Naproxen Sodium Naproxen Sodium Oxaprozin Piroxicam Salsalate Sulindac Tolmetin Sodium
Anaprox Anaprox DS Daypro Feldene Disalcid Clinoril Tolmetin Sodium
PA (MedImpact)
Excludes controlled-release formulations
COX-2 Inhibitor Agents SC Tier 2
Celecoxib
Celebrex
PA (MedImpact) If Step Care Not Met
Disease Modifying Antirheumatic Agents (DMARDs) Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2
Azathioprine Hydroxychloroquine Leflunomide Methotrexate Methotrexate Sulfasalazine Penicillamine
Imuran Plaquenil Arava Rheumatrex Trexall Azulfidine Cuprimine
Anti-inflammatory, Anti-arthritic Agents, Miscellaneous QL $0 Co-payment
Hyaluronan
Orthovisc
Quantity Limit: 8 syringes per 120 days; Specialty Pharmacy - Caremark 13
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
QL $0 Co-payment
Hylan G-F 20
Synvisc
QL $0 Co-payment
Hylan G-F 20
Synvisc-One
QL $0 Co-payment
Sodium Hyaluronate
Euflexxa
QL $0 Co-payment
Sodium Hyaluronate
Hyalgan
QL $0 Co-payment
Sodium Hyaluronate
Supartz
Quantity Limit: 6 syringes per 120 days; Specialty Pharmacy - Caremark Quantity Limit: 2 syringes per 120 days; Specialty Pharmacy - Caremark Quantity Limit: 6 syringes per 120 days; Specialty Pharmacy - Caremark Quantity Limit: 10 syringes per 120 days; Specialty Pharmacy - Caremark Quantity Limit: 10 syringes per 120 days; Specialty Pharmacy - Caremark
Anti-inflammatory, Tumor Necrosis Factor Inhibitor PA Tier 2
Adalimumab
Humira
PA Tier 2
Certolizumab
Cimzia
PA Tier 2
Etanercept
Enbrel
PA Tier 2
Golimumab
Simponi
PA $0 Co-payment
Infliximab
Remicade
PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark
Migraine Agents
Tier 1 Tier 1 Tier 1 Tier 1 QL Tier 1
APAP/Dichloralphenazone/ Isometheptene Butalbital/APAP Butalbital/APAP/Caffeine Butalbital/APAP/Caffeine Butalbital/Aspirin/Caffeine Dihydroergotamine
Phrenilin Esgic Plus Fioricet Fiorinal D.H.E. 45
Quantity Limit: 1 pack (4) per 30 days
QL Tier 1
Dihydroergotamine
Migranal
Quantity Limit: 1 pack (4) per 30 days
Tier 1 Tier 1 SC Tier 1
Divalproex ER Ergotamine/Caffeine Naratriptan
Depakote ER Cafergot Amerge
QL Tier 1 QL Tier 1
Sumatriptan Sumatriptan
Imitrex Imitrex Injection
QL Tier 1
Sumatriptan
Imitrex Nasal Spray
Tier 1
Midrin
PA (MedImpact) If Step Care Not Met; Quantity Limit: 9 tablets per 30 days Quantity Limit: 9 tablets per 30 days Quantity Limit: 5 vials or 4 injectable kits per 30 days Quantity Limit: 6 units per 30 days 14
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
SC Tier 2
Almotriptan
Axert
Tier 2 QL Tier 2
Butalbital/APAP Dihydroergotamine
Phrenilin Forte Migranal Nasal
SC Tier 2
Eletriptan
Relpax
Tier 2 SC Tier 2
Ergotamine Tartrate Frovatriptan
Ergomar Frova
SC Tier 2
Rizatriptan Succinate
Maxalt/Maxalt MLT
SC Tier 2
Zolmitriptan
Zomig Nasal
SC Tier 2
Zolmitriptan
Zomig/Zomig ZMT
PA (MedImpact) If Step Care Not Met; Quantity Limit: 9 tablets per 30 days Quantity Limit: 1 package of 8 units per 30 days PA (MedImpact) If Step Care Not Met; Quantity Limit: 9 tablets per 30 days PA (MedImpact) If Step Care Not Met; Quantity Limit: 9 tablets per 30 days PA (MedImpact) If Step Care Not Met; Quantity Limit: 9 tablets per 30 days PA (MedImpact) If Step Care Not Met; Quantity Limit: 6 units per 30 days PA (MedImpact) If Step Care Not Met; Quantity Limit: 9 tablets per 30 days
Opiate Agonists Butalbital/APAP/Caffeine/ Codeine Butalbital/Aspirin/Codeine Codeine Phosphate Codeine Sulfate Codeine/Acetaminophen Codeine/Aspirin Dihydrocodeine/APAP/Caffeine Fentanyl Fentanyl Hydrocodone/Acetaminophen Hydrocodone/Acetaminophen Hydrocodone/Ibuprofen Hydrocodone/Ibuprofen Hydromorphone Meperidine Methadone HCl Morphine Morphine SR Oxycodone Oxycodone Oxycodone/Acetaminophen Oxycodone/Acetaminophen Oxycodone/Aspirin Oxymorphone
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 PA Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 PA Tier 1
Fioricet/Codeine Fiorinal/Codeine Codeine Phosphate Codeine Sulfate Tylenol #2, #3, #4 Empirin #2, #3, #4 Panlor DC Actiq Lozenge Duragesic Vicodin Vicodin ES Reprexain Vicoprofen Dilaudid Demerol Methadone MSIR MS Contin Oxyfast Oxyir Percocet Tylox Percodan Opana
PA (MedImpact)
PA (MedImpact) 15
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
PA PA PA PA PA
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Buprenorphine, Transdermal Fentanyl Fentanyl Fentanyl Hydromorphone, Extended-release Morphine SR Morphine SR Oxycodone, Controlled-Release Oxymorphone, Extended-release
PA Tier 2 PA Tier 2 QL Tier 2 PA Tier 2
Butrans Abstral Sublingual Tablets Fentora Buccal Tablet Onsolis Buccal Film Exalgo
PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact)
Avinza Kadian OxyContin
PA (MedImpact) PA (MedImpact) Quantity Limit: 90 tablets per 30 days PA (MedImpact)
Opana ER
Opiate Antagonists Tier 1 PA Tier 2 PA $0 Co-payment
Naltrexone Methylnaltrexone Naltrexone
Revia Relistor Vivitrol
PA (Network Health) PA (NetworkHealth) Specialty Pharmacy - Caremark
Opiate Agonists/Antagonists Tier 1
Butorphanol Tartrate
Stadol
Miscellaneous Analgesics Tier 1 Tier 1 PA Tier 1 PA Tier 2
Tramadol Tramadol HCl/APAP Tramadol, Extended-release Tramadol, Extended-release
Ultram Ultracet Ultram ER Ultram ER 300mg
PA (MedImpact) PA (MedImpact)
Miscellaneous Opiate Agents
2
PA Tier 1 QL Tier 2
Buprenorphine Buprenorphine/Naloxone
Subutex Suboxone 2mg
QL Tier 2
Buprenorphine/Naloxone
Suboxone 8mg
Alzheimer’s Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2
3
PA (Network Health) Quantity Limit: 90 tablets per 30 days; excludes Suboxone Film Quantity Limit: 90 tablets per 30 days; excludes Suboxone Film
Donepezil Donepezil Galantamine Galantamine Memantine Rivastigmine Rivastigmine Transdermal Tacrine HCl
Aricept Aricept ODT Razadyne Razadyne ER Namenda Exelon Exelon Patch Cognex
Anticonvulsant Agents Tier 1 Tier 1 Tier 1
Carbamazepine Carbamazepine XR Carbamazepine XR
Tegretol Carbatrol Tegretol XR 200mg and 400mg 16
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 1
Clonazepam
Klonopin
Tier 1 Tier 1 Tier 1 Tier 1 QL Tier 1
Divalproex Sodium Ethosuximide Gabapentin Gabapentin Lamotrigine
Tier 1 QL Tier 1
Lamotrigine Lamotrigine
Depakote Zarontin Gabarone Neurontin Lamictal 100mg and 150mg Lamictal 200mg Lamictal 25mg
QL Tier 1
Lamotrigine Chewable Tablets
Lamictal 5mg and 25mg
Levetiracetam Oxcarbazepine Phenobarbital Phenytoin
Tier 1 Tier 1 Tier 1 Tier 1
4
Tier 1 QL Tier 1
Primidone Topiramate
Keppra Trileptal Phenobarbital Dilantin 100mg Capsule & Oral Suspension Mysoline Topamax 25mg
QL Tier 1
Topiramate
Topamax 50mg & 100mg
Tier 1 Tier 1 Tier 2 QL Tier 2
Valproic Acid Zonisamide Carbamazepine XR Diazepam
Depakene Zonegran Tegretol XR 100mg Diastat
QL Tier 2
Diazepam
Diastat AcuDial
Tier 2 PA Tier 2 PA Tier 2 PA Tier 2 Tier 2 Tier 2 Tier 2
Gabapentin Lacosamide Lamotrigine, Extended Release Levetiracetam ER Mephobarbital Oxcarbazepine Phenytoin
Tier 2 PA Tier 2 PA Tier 2 Tier 2
Phenytoin Pregabalin Rufinamide Tiagabine
Neurontin Oral Solution Vimpat Lamictal XR Keppra XR Mebaral Trileptal Oral Suspension Dilantin 30mg Capsules & 50mg Chew Tabs Phenytek Lyrica Banzel Gabitril
Excludes orally disintegrating tablet formulation
Quantity Limit: 90 tablets per 30 days
Quantity Limit: 180 tablets per 30 days Quantity Limit on 25mg strength: 180 tablets per 30 days
Quantity Limit: 180 tablets or capsules per 30 days Quantity Limit: 90 tablets per 30 days
Quantity Limit: 1 twin pack (2 doses) per Rx Quantity Limit: 1 twin pack (2 doses) per Rx PA (MedImpact) PA (MedImpact) PA (MedImpact)
PA (MedImpact) PA (MedImpact)
Antiparkinsonian Agents Tier 1 Tier 1 Tier 1 Tier 1
Amantadine Benztropine Bromocriptine Cabergoline
Symmetrel Cogentin Parlodel Dostinex 17
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 QL Tier 2
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 PA Tier 2 5
Carbidopa/Levodopa Carbidopa/Levodopa CR Carbidopa/Levodopa ODT Pramipexole Ropinirole Selegiline Trihexyphenidyl Apomorphine
Sinemet Sinemet CR Parcopa Mirapex Requip Eldepryl Artane Apokyn
Biperiden Carbidopa Carbidopa/Levodopa/ Entacapone Entacapone Pramipexole ER Procyclidine Rasagiline Ropinirole ER Selegiline ODT
Akineton Lodosyn Stalevo Comtan Mirapex ER Kemadrin Azilect Requip XL Zelapar
Specialty Pharmacy - Caremark; Quantity Limit: 15 cartridges (450mg) per 30 days
PA (MedImpact)
Muscle Relaxant Agents Skeletal Muscle Relaxants Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 SC Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Baclofen Carisoprodol Carisoprodol/Aspirin Chlorzoxazone Cyclobenzaprine Dantrolene Sodium Diazepam Metaxalone
Baclofen Soma Soma Compound Parafon DSC Flexeril Dantrium Valium Skelaxin
Methocarbamol Orphenadrine Citrate Orphenadrine/Aspirin/Caffeine Orphenadrine/Aspirin/Caffeine Tizanidine tablet
Robaxin Norflex Norgesic Orphengesic Forte Zanaflex Tablet
Excludes 250mg tablet
PA (MedImpact) If Step Care Not Met
Excludes capsule formulation
Neuromuscular Blocking Agents PA $0 Co-payment
AbobotulinumtoxinA
Dysport
PA $0 Co-payment
IncobotulinumtoxinA
Xeomin
PA $0 Co-payment
OnabotulinumtoxinA
Botox
PA $0 Co-payment
RimabotulinumtoxinB
Myobloc
PA (Network Health) Specialty Pharmacy - Caremark PA (Network Health) Specialty Pharmacy - Caremark PA (Network Health) Specialty Pharmacy - Caremark PA (Network Health) Specialty Pharmacy - Caremark
Amyotrophic Lateral Sclerosis Agents Tier 2
Riluzole
Rilutek 18
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
6
Parasympathomimetic (Cholinergic) Agents Tier 1 Tier 2
7
Pyridostigmine Pyridostigmine
Mestinon Mestinon Timespan
Psychotherapeutic Agents Tricyclic Antidepressant Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Amitriptyline Amoxapine Clomipramine Desipramine Doxepin Imipramine HCl Maprotiline Nortriptyline
Elavil Asendin Anafranil Norpramin Sinequan Tofranil Ludiomil Pamelor
Citalopram Fluoxetine Fluvoxamine Paroxetine Paroxetine Sertraline Escitalopram Oxalate Fluvoxamine, Controlled-Release Paroxetine
Celexa Prozac Luvox Paxil Paxil CR Zoloft Lexapro Luvox CR
S.S.R.I. Agents Tier 1 Tier 1 Tier 1 Tier 1 PA Tier 1 Tier 1 PA Tier 2 PA Tier 2 Tier 2
PA (MedImpact) PA (MedImpact) PA (MedImpact)
Paxil Suspension
M.A.O. Inhibitor Agents Tier 1 Tier 1
Phenelzine Tranylcypromine
Nardil Parnate
Miscellaneous Antidepressant Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 QL Tier 2
Bupropion Bupropion SR Bupropion SR Mirtazapine Mirtazapine Nefazodone Trazodone
Wellbutrin Wellbutrin SR Wellbutrin XL Remeron Remeron Soltab Serzone Desyrel
Venlafaxine Venlafaxine, Extended Release Venlafaxine, Extended Release Desvenlafaxine
Effexor Effexor XR Venlafaxine ER Tablets Pristiq
Excludes 300mg; use two 150mg tablets
Quantity Limit on 50mg strength: 30 tablets per 30 days
19
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
SC Tier 2
Duloxetine
Cymbalta
PA (MedImpact) If Step Care Not Met; Quantity Limit on 30mg strength: 30 capsules per 30 days; 20mg and 60mg strengths: 60 capsules per 30 days
PA Tier 2 SC Tier 2
Selegiline Transdermal Trazodone, Extended-Release
EMSAM Oleptro
PA (MedImpact) PA (MedImpact) If Step Care Not Met
Antimanic Agents Tier 1 Tier 1
Lithium Carbonate (all forms) Lithium Carbonate (all forms)
Eskalith Lithobid
Psychotherapeutic Combination Agents PA Tier 2
Olanzapine/Fluoxetine
Symbyax
PA (MedImpact)
Xanax Librium Valium Dalmane Ativan Serax Restoril
Excludes 7.5mg and 22.5mg capsules
Quantity Limit: 60 tablets per 30 days
Quantity Limit: 30 tablets per 30 days
Benzodiazepines Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Alprazolam Chlordiazepoxide Diazepam Flurazepam Lorazepam Oxazepam Temazepam
Antipsychotic Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Chlorpromazine Clozapine Fluphenazine Haloperidol Haloperidol Decanoate Injection
Tier 1 Tier 1 Tier 1 QL Tier 1
Haloperidol Lactate Injection Loxapine Perphenazine Risperidone
Thorazine Clozaril Prolixin Haldol Haldol Decanoate 50mg vial & 100mg vial & ampule Haldol Loxitane Trilafon Risperdal
Tier 1 Tier 1 Tier 1 QL Tier 2
Thioridazine Thiothixene Trifluoperazine Aripiprazole
Mellaril Navane Stelazine Abilify
PA Tier 2 Tier 2
Asenapine Haloperidol Decanoate Injection
PA Tier 2 PA Tier 2 QL Tier 2
Iloperidone Lurasidone Olanzapine
Saphris Haldol Decanoate 50mg ampule Fanapt Latuda Zyprexa
PA (MedImpact)
PA (MedImpact) PA (MedImpact) Quantity Limit: 30 tablets per 30 days 20
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
QL Tier 2
Olanzapine
Zyprexa Zydis
PA Tier 2 QL Tier 2
Paliperidone Quetiapine
Invega Seroquel
QL Tier 2
Quetiapine, extended-release
Seroquel XR
QL Tier 2
Ziprasidone HCl
Geodon
QL $0 Co-payment
Olanzapine
Zyprexa Relprevv
PA $0 Co-payment QL $0 Co-payment
Paliperidone Risperidone Injection
Invega Sustenna Risperdal Consta
Quantity Limit: 30 tablets per 30 days PA (MedImpact) Quantity Limit: 90 tablets per 30 days Quantity Limit: 50mg, 300mg & 400mg: 60 tablets per 30 days; 150mg & 200mg: 30 tablets per 30 days Quantity Limit: 60 capsules per 30 days Quantity Limit: 210mg and 300mg vials: 2 injections per 28 days; 405mg vial: 1 injection per 28 days PA (MedImpact) Quantity Limit: 2 injections per 28 days
Miscellaneous Anxiolytics, Sedatives and Hypnotics Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 QL Tier 1
Buspirone Chloral Hydrate Hydroxyzine Hydroxyzine Pamoate Promethazine Zaleplon
Buspar Noctec Atarax Vistaril Phenergan Sonata
QL Tier 1
Zolpidem
Ambien
PA PA PA PA PA PA
Zolpidem, Controlled-Release Eszopiclone Ramelteon Sodium Oxybate Zolpidem, Controlled-Release Zolpidem, Sublingual
Ambien CR 6.25mg Lunesta Rozerem Xyrem Ambien CR 12.5mg Edluar
Quantity Limit: 30 capsules per 30 days Quantity Limit: 30 tablets per 30 days PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact)
Savella
Quantity Limit: 60 tablets per 30 days
Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Fibromyalgia Agents QL Tier 2
Milnacipran
Systemic Stimulant Agents CNS Stimulants Not covered as appetite suppressants; up to 60-day supply of dextroamphetamine or methyphenidate can be pescribed for treatment of ADHD or narcolepsy. Tier 1 Dexmethylphenidate Focalin Tier 1 Dextroamphetamine Dexedrine Dextroamphetamine/ Amphetamine Salts Dextroamphetamine/ Amphetamine Salts Methylphenidate Methylphenidate
Tier 1 QL Tier 1 Tier 1 Tier 1
Adderall Adderall XR
Quantity Limit on 5mg, 10mg, and 15mg strengths: 30 capsules per 30 days
Ritalin Ritalin SR 21
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
QL Tier 1
Methylphenidate ER
Concerta
QL Tier 2
Armodafinil
Nuvigil
QL Tier 2
Dexmethylphenidate
Focalin XR
QL Tier 2 QL Tier 2
Dextroamphetamine Lisdexamfetamine
LiQuadd Vyvanse
QL Tier 2
Methylphenidate ER
Metadate CD
QL Tier 2
Methylphenidate ER
Ritalin LA
PA Tier 2 QL Tier 2
Methylphenidate, Transdermal Modafinil
Daytrana Provigil
9
Non-Stimulant ADHD Agents PA Tier 2 PA Tier 2 SC Tier 2
2.00 1
Quantity Limit on 18mg and 27mg strengths: 30 tablets per 30 days Quantity Limit on 150mg and 250mg strengths: 30 tablets per 30 days; 50mg strength: 60 tablets per 30 days Quantity Limit on 5mg, 10mg, 15mg, and 20mg strengths: 30 capsules per 30 days Quantity Limit: 1,200ml per 30 days Quantity Limit: 30 capsules per 30 days Quantity Limit on 10mg, 20mg, and 30mg strengths: 30 capsules per 30 days Quantity Limit on 10mg and 20mg strengths: 30 capsules per 30 days PA (MedImpact) Quantity Limit: 30 tablets per 30 days
Atomoxetine Clonidine Extended-Release Guanfacine Extended-Release
Strattera Kapvay Intuniv
PA (MedImpact) PA (MedImpact) PA (MedImpact) If Step Care Not Met; Quantity Limit: 30 tablets per 30 days
Cardiovascular/Blood Agents Anti-arrhythmic Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Amiodarone Amiodarone Disopyramide Flecainide Mexiletine Procainamide Propafenone Propafenone, Extended Release Quinidine Gluconate Quinidine Sulfate Sotalol Disopyramide CR Dofetilide Dronedarone Moricizine Procainamide SR
Cordarone Pacerone Norpace Tambocor Mexitil Pronestyl Rythmol Rythmol SR Quinaglute Quinidine Betapace Norpace CR Tikosyn Multaq Ethmozine Procanbid
Specialty Pharmacy - Caremark
2
22
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Antihypertensive Agents Direct Renin Inhibitor PA Tier 2
Aliskiren
Tekturna
PA (MedImpact)
Peripherally Acting Adrenergic Agents Tier 2
Reserpine
Reserpine
Beta-adrenergic Antagonist Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 SC Tier 2
Acebutolol Atenolol Betaxolol Bisoprolol Metoprolol Succinate Metoprolol Tartrate Nadolol Pindolol Propranolol Propranolol LA Timolol Nebivolol
Sectral Tenormin Kerlone Zebeta Toprol XL Lopressor Corgard Visken Inderal Inderal LA Blocadren Bystolic
PA (MedImpact) If Step Care Not Met
Coreg Normodyne Trandate Coreg CR
PA (MedImpact) If Step Care Not Met
Combination Alpha-beta Antagonist Agents Tier 1 Tier 1 Tier 1 SC Tier 2
Carvedilol Labetalol Labetalol Carvedilol, Controlled-Release
Angiotensin Converting Enzyme Inhibitor Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Benazepril Captopril Enalapril Fosinopril Lisinopril Lisinopril Moexipril Perindopril Quinapril Ramipril Trandolapril
Lotensin Capoten Vasotec Monopril Prinivil Zestril Univasc Aceon Accupril Altace Mavik
Angiotensin Receptor Blocker Agents Tier 1 SC Tier 2
Losartan Irbesartan
Cozaar Avapro
PA (MedImpact) If Step Care Not Met
SC Tier 2
Olmesartan
Benicar
PA (MedImpact) If Step Care Not Met
SC Tier 2
Valsartan
Diovan
PA (MedImpact) If Step Care Not Met
Calcium Channel Blocking Agents Tier 1
Amlodipine
Norvasc 23
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
PA
PA
PA
PA PA
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2
Diltiazem Diltiazem CD Diltiazem LA Diltiazem SA Capsules Diltiazem SA Capsules Diltiazem SA Capsules Diltiazem SA Capsules Diltiazem SR Felodipine Isradipine Nicardipine Nifedipine Nifedipine Nifedipine SR (all forms) Nifedipine SR (all forms) Nimodipine Nisoldipine ER Verapamil Verapamil SR Capsules Verapamil SR Tablets Isradipine CR Verapamil SR Verapamil SR Capsules
Cardizem Cardizem CD Cardizem LA Cartia XT Dilacor XR Diltia XT Tiazac Cardizem SR Plendil Dynacirc Cardene Adalat Procardia Adalat CC Procardia XL Nimotop Sular Calan Verelan Calan SR Dynacirc CR Covera HS Verelan PM
PA (MedImpact)
PA (MedImpact)
PA (MedImpact)
PA (MedImpact) PA (MedImpact)
Centrally Acting Adrenergic Agents Tier 1 Tier 1 Tier 1 Tier 1 PA Tier 2
Clonidine Clonidine Transdermal Guanfacine Methyldopa Clonidine Extended-Release
Catapres Catapres-TTS Tenex Aldomet Nexiclon XR
PA (MedImpact)
Combination Antihypertensive Agents Tier 1 QL Tier 1
Atenolol/Chlorthalidone Benazepril/Amlodipine
Tenoretic Lotrel
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 PA Tier 2 PA Tier 2
Benazepril/HCTZ Bisoprolol/HCTZ Captopril/HCTZ Enalapril/HCTZ Fosinopril/HCTZ Lisinopril/HCTZ Lisinopril/HCTZ Losartan/HCTZ Moexipril/HCTZ Quinapril/HCTZ Aliskiren/Amlodipine Aliskiren/Amlodipine/HCTZ
Lotensin HCT Ziac Capozide Vaseretic Monopril-HCT Prinzide Zestoretic Hyzaar Uniretic Accuretic Tekamlo Amturnide
Quantity Limit: 30 capsules per 30 days
PA (MedImpact) PA (MedImpact) 24
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
PA PA PA PA PA SC
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Aliskiren/HCTZ Aliskiren/Valsartan Amlodipine/Olmesartan Amlodipine/Valsartan Amlodipine/Valsartan/HCTZ Irbesartan/HCTZ
Tekturna HCT Valturna Azor Exforge Exforge HCT Avalide
SC Tier 2
Olmesartan/HCTZ
Benicar HCT
SC Tier 2
Valsartan/HCTZ
Diovan HCT
PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) If Step Care Not Met PA (MedImpact) If Step Care Not Met PA (MedImpact) If Step Care Not Met
Antihypertensive, Pulmonary Arterial PA Tier 1
Epoprostenol
Flolan
PA Tier 2
Ambrisentan
Letairis
PA Tier 2
Bosentan
Tracleer
PA Tier 2
Iloprost
Ventavis
PA Tier 2
Sildenafil Citrate
Revatio Tablets
PA Tier 2
Tadalafil
Adcirca
PA Tier 2
Treprostinil
Remodulin
PA Tier 2
Treprostinil
Tyvaso
PA $0 Co-payment
Sildenafil Citrate
Revatio Injection
PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark
Drugs for Pheochromocytoma Tier 2
Phenoxybenzamine
Dibenzyline
Potassium-sparing Diuretics Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Amiloride Amiloride/HCTZ Spironolactone Spironolactone/HCTZ Triamterene/HCTZ Triamterene/HCTZ
Midamor Moduretic Aldactone Aldactazide Dyazide Maxzide
Selective Aldosterone Antagonist PA Tier 1
Eplerenone
Inspra
Bumetanide Furosemide Torsemide
Bumex Lasix Demadex
PA (MedImpact)
Loop Diuretics Tier 1 Tier 1 Tier 1
Thiazide and Related Diuretics Tier 1
Chlorothiazide
Diuril 25
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 1 Tier 1 Tier 1 Tier 1
Chlorthalidone Hydrochlorothiazide (HCTZ) Indapamide Metolazone
Hygroton Hydrodiuril Lozol Zaroxolyn
Alpha Antagonist Agents Tier 1 Tier 1 Tier 1 Tier 1
Doxazosin Prazosin Terazosin Yohimbine
Cardura Minipress Hytrin Yovital
Direct Vasodilator Agents Tier 1 Tier 1 3
Apresoline Minoxidil Tablet
Antihyperlipidemic Agents
PA
PA PA PA PA PA PA PA PA PA
PA PA 4
Hydralazine Minoxidil tablet
Tier 1 Tier 1 Tier 1 Tier 1
Cholestyramine/Aspartame Cholestyramine/Sucrose Colestipol Fenofibrate
Questran Light Questran Colestipol Lofibra
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 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Gemfibrozil Lovastatin Pravastatin Simvastatin Atorvastatin Atorvastatin Colesevelam Ezetimibe Ezetimibe/Simvastatin Fenofibrate Fenofibrate Fenofibrate Fenofibrate Fenofibrate Fluvastatin Fluvastatin XL Lovastatin/Niacin Niacin ER Pitavastatin Rosuvastatin
Lopid Mevacor Pravachol Zocor Lipitor 10mg & 20mg Lipitor 40mg & 80mg Welchol Zetia Vytorin Antara Fenoglide Lipofen Tricor Triglide Lescol Lescol XL Advicor Niaspan Livalo Crestor
Includes 54mg and 160mg tablets, and 67mg, 134mg, and 200mg capsules
PA (MedImpact)
PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact)
PA (MedImpact) PA (MedImpact)
Antihyperlipidemic Combination Agents PA Tier 2
Atorvastatin/Amlodipine
Caduet
PA (MedImpact)
5
26
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Antiplatelet Agents
6
Tier 1
Anagrelide
Agrylin
Tier 1 Tier 1 Tier 2 Tier 2
Dipyridamole Ticlopidine Clopidogrel Prasugrel
Persantine Ticlid Plavix Effient
Antiplatelet Combination Agents PA Tier 2 7
Aspirin/Dipyridamole
Aggrenox
PA (MedImpact)
Amicar Lysteda
PA (MedImpact)
Hematological Agents Antifibrinolytic Agents Tier 1 PA Tier 2
Aminocaproic Acid Tranexamic Acid
Coagulants and Anticoagulants Tier 1 Tier 1 Tier 1 Tier 1 QL Tier 2
Enoxaparin Fondaparinux Heparin Warfarin Dabigatran
Lovenox Arixtra Heparin Sodium Coumadin Pradaxa
Tier 2 QL Tier 2 Tier 2
Dalteparin Desirudin Tinzaparin
Fragmin Iprivask Innohep
Quantity Limit: 24 vials for 12 days
Aranesp Epogen Procrit Neupogen Neulasta Leukine
Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy Caremark PA (Caremark) Specialty Pharmacy Caremark
Quantity Limit: 60 tablets per 30 days
Colony Stimulating Factors Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Darbepoetin Epoetin Alpha Epoetin Alpha Filgrastim Peg-Filgrastim Sargramostim
Thrombopoietin Agonists
9
PA Tier 2
Eltrombopag
Promacta
PA $0 Co-payment
Romiplostim
Nplate
Cardiac Glycoside Agents Tier 1
10
Digoxin
Lanoxin
Hemorheologic Agents Tier 1 Tier 1
Cilostazol Pentoxifylline
Pletal Trental
Nitrate Agents 11
Isosorbide Dinitrate
Tier 1
Isordil 27
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 12
Isosorbide Dinitrate SR Isosorbide Mononitrate Isosorbide Mononitrate Nitroglycerin Patches Nitroglycerin Patches Nitroglycerin Sublingual Nitroglycerin Ointment Nitroglycerin Spray Nitroglycerin Sublingual
Anti-anginal and Anti-ischemic Agents, Non-hemodynamic PA Tier 2
3.00 1
Dilatrate SR Imdur Monoket Nitrek Nitro-Dur Nitroquick Nitrobid Nitrolingual Spray Nitrostat SL
Ranolazine
Ranexa
PA (MedImpact)
Gastrointestinal Agents Antidiarrheal Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Anhydrous Morphine Attapulgite Diphenoxylate/Atropine Loperamide Opium Tincture
Paregoric Parepectolin Lomotil Imodium Opium
Selective 5-HT3 Receptor Antagonist PA Tier 2 2
Alosetron
Lotronex
PA (MedImpact)
Anti-emetic Agents Tier 1 QL Tier 1 QL Tier 1 Tier 1 Tier 1 Tier 1 QL Tier 1 QL Tier 1 QL Tier 1 Tier 1 Tier 1 Tier 1 QL Tier 2 QL Tier 2
Dronabinol Granisetron Granisetron Meclizine Metoclopramide Metoclopramide Ondansetron HCl Ondansetron HCl Ondansetron HCl Prochlorperazine Maleate Promethazine Trimethobenzamide Aprepitant Dolasetron
Marinol Kytril Oral Solution Kytril Tablet Antivert Reglan Reglan Injection Zofran ODT Zofran Solution Zofran Tablet Compazine Phenergan Tigan Emend Anzemet Injection
QL Tier 2
Dolasetron
Anzemet Tablet
PA Tier 2
Granisetron
QL Tier 2
Palonosetron
Sancuso Transdermal Patch Aloxi Injection
Quantity Limit: 70ml per Rx Quantity Limit: 14 tablets per Rx
Quantity Limit: 21 tablets per Rx Quantity Limit: 105ml per Rx Quantity Limit: 21 tablets per Rx
Quantity Limit: 6 capsules per Rx Quantity Limit: 1 box or 25ml per Rx Quantity Limit: ten 50mg tablets or five 100mg tablets per Rx PA (MedImpact) Quantity Limit: 1 box or 20ml per Rx 28
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 2 QL $0 Co-payment 3
Belladonna/Phenobarbital Chlordiazepoxide/ Clidinium Dicyclomine Ergotamine/Belladonna/ Phenobarbital Glycopyrrolate Hyoscyamine Sulfate Hyoscyamine Sulfate Hyoscyamine Sulfate Belladonna/Phenobarbital Glycopyrrolate
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2
6
Quantity Limit: 2 vials per Rx
Donnatal Chlordiazepoxide/ Clidinium Bentyl Bellergal S Glycopyrrolate Levbid Levsin Nulev Donnatal Extentabs Cuvposa Solution
Anti-ulcer Agents Tier 1 Tier 1 Tier 2
5
Transderm-Scop Emend Injection
Antimuscarinic/Antispasmodic Agents Tier 1 Tier 1
4
Scopolamine Fosaprepitant
Misoprostol Sucralfate Sucralfate
Cytotec Carafate Carafate Suspension
Proton Pump Inhibitors PA Tier 1 Tier 1 PA Tier 1
Lansoprazole Lansoprazole Lansoprazole
Prevacid (Rx) Prevacid OTC Prevacid SoluTab
Tier 1 Tier 1 Tier 1 PA Tier 2 PA Tier 2
Omeprazole Omeprazole Magnesium Pantoprazole Esomeprazole Omeprazole
Prilosec (Rx) Prilosec OTC Protonix Nexium Prilosec Granules
PA Tier 2
Pantoprazole
Protonix Granules
PA Tier 2
Rabeprazole
Aciphex
PA (MedImpact) PA (MedImpact) if member age > 13 years
PA (MedImpact) PA (MedImpact) if member age > 13 years PA (MedImpact) if member age > 13 years PA (MedImpact)
Bowel Evacuant Agents Tier 1 Tier 1 Tier 2
Oral Bowel Evacuant Solution Oral Bowel Evacuant Solution Oral Bowel Evacuant Combination Oral Bowel Evacuant Solution Oral Bowel Evacuant Solution Oral Bowel Evacuation Tablets
Tier 2 Tier 2 QL Tier 2
Colyte Golytely HalfLytely MoviPrep Suprep OsmoPrep
Quantity Limit: 32 tablets per Rx
7
29
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Digestive Enzymes Tier 1 Tier 2 Tier 2 Tier 2 8
Amylase/Lipase/Protease Amylase/Lipase/Protease Amylase/Lipase/Protease Amylase/Lipase/Protease
Gallstone Solubilizing Agents Tier 1 Tier 1 Tier 1
9
Ursodiol Ursodiol Ursodiol
Metoclopramide Lubiprostone
Cimetidine Famotidine Nizatidine Ranitidine
Lactulose Polyethylene Glycol Lactulose
Tagamet Pepcid Axid Zantac
Enulose Miralax Kristalose Packets
Ulcer Eradication Agents Lansoprazole/Amoxicillin/ Clarithromycin Tetracycline/Bismuth/ Metronidazole Tetracycline/Bismuth/ Metronidazole
Tier 2 Tier 2 Tier 2 13
PA (MedImpact)
Laxative Agents Tier 1 Tier 1 Tier 2
12
Reglan Amitiza
H2 Antagonist Agents Tier 1 Tier 1 Tier 1 Tier 1
11
Actigall Urso Urso Forte
Gastrointestinal Stimulant Agents Tier 1 PA Tier 2
10
Pancrelipase Creon Pancreaze Zenpep
Prevpac Helidac Pylera
Ulcerative Colitis/Crohns’ Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2
Balsalazide Budesonide Hydrocortisone Enema Mesalamine Enema Sulfasalazine Hydrocortisone Acetate Mesalamine CR Capsules Mesalamine DR Tablets
Colazal Entocort EC Cortenema Rowasa Azulfidine Cortifoam Pentasa Asacol
30
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
SC Tier 2 Tier 2 Tier 2 Tier 2 4.00 1
Mesalamine ER Capsule Mesalamine Suppositories Olsalazine
Apriso Canasa Dipentum
PA (MedImpact) If Step Care Not Met
Amebicides Iodoquinol (Diiodohydroxyquin) Metronidazole Paromomycin Metronidazole, Extended Release
Yodoxin Flagyl Humatin Flagyl ER
Antihelmintic Agents Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
3
Lialda
Anti-infective Agents
Tier 1 Tier 1 Tier 1 Tier 2 2
Mesalamine DR Tablets
Mebendazole Albendazole Furazolidone Ivermectin Praziquantel Thiabendazole
Vermox Albenza Furoxone Stromectol Biltricide Mintezol
Antibiotic Agents Aminoglycosides Tier 1 Tier 2
Neomycin Sulfate Tobramycin/ Sodium Chloride 0.2%
Neomycin Tobi
Specialty Pharmacy - Caremark
Cephalosporins Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2
Cefaclor Cefadroxil Cefdinir Cefditoren Pivoxil Cefpodoxime Cefprozil Cephalexin Cefixime Ceftibuten Dihydrate Cefuroxime
Ceclor Duricef Omnicef Spectracef Vantin Cefzil Keflex Suprax Cedax Ceftin
Telithromycin
Ketek
Ketolides Tier 2
Macrolide Antibiotic Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Azithromycin Clarithromycin Clarithromycin Erythromycin Base Erythromycin Base IR Tablet
Zithromax Biaxin Biaxin XL Ery-Tab Erythromycin 31
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2
Erythromycin Ethylsuccinate Erythromycin Ethylsuccinate Erythromycin Stearate Erythromycin/Sulfisoxazole Azithromycin Erythromycin Base
EES EryPed Suspension Erythrocin Pediazole Zmax PCE
Miscellaneous Antibiotic Agents Tier 1 Tier 1 Tier 2 Tier 2 QL Tier 2 Tier 2 QL Tier 2
Tier 2 Tier 2
Clindamycin HCl Metronidazole Aztreonam Fosfomycin Tromethamine Linezolid
Clindamycin HCl Flagyl Cayston Monurol Zyvox
Metronidazole, Extended Release Rifaximin
Flagyl ER
Tinidazole Vancomycin
Tindamax Vancocin
Amoxicillin Amoxicillin Amoxicillin/ Potassium Clavulanate Amoxicillin/ Potassium Clavulanate Amoxicillin/ Potassium Clavulanate Ampicillin Dicloxacillin Penicillin VK Penicillin G Benzathine
Amoxil Trimox Augmentin
Ciprofloxacin Ciprofloxacin Levofloxacin Ofloxacin Gatifloxacin 0.3% Gemifloxacin Moxifloxacin HCl Moxifloxacin HCl Norfloxacin
Cipro Cipro XR Levaquin Floxin Tequin Factive Avelox Avelox ABC Pack Noroxin
Erythromycin/Sulfisoxazole
Pediazole
Xifaxan
Quantity Limit: 1.2gm/day for 14 days, then PA
Quantity Limit on 200mg strength: 9 tablets per 30 days; Quantity Limit on 550mg strength: 6 tablets per 30 days
Penicillins Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2
Augmentin ES Augmentin XR Principen Dicloxacillin Pen VK Bicillin LA
Quinolones Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Sulfonamides Tier 1
32
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 1 Tier 1 Tier 1 Tier 2
Sulfadiazine Sulfamethoxazole/ Trimethoprim (SMZ/TMP) Sulfamethoxazole/ Trimethoprim (SMZ/TMP) Sulfisoxazole
Sulfadiazine Bactrim
Doxycycline Doxycycline Minocycline Minocycline Tetracycline
Vibramycin Vibra-Tabs Dynacin Minocin Sumycin
Septra Gantrisin
Tetracyclines Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 4
5
6
Antifungal Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 QL Tier 1
Clotrimazole Fluconazole Itraconazole Ketoconazole Nystatin Terbinafine (oral)
Mycelex Troche Diflucan Sporanox Nizoral Mycostatin Lamisil
Tier 2 Tier 2 PA Tier 2
Griseofulvin Microsize Griseofulvin Ultramicrosize Terbinafine (oral)
Grifulvin V Gris-Peg Lamisil Granules
PA (MedImpact)
Antimalarial Agents Tier 1 Tier 1 Tier 1 QL Tier 2
Chloroquine Phosphate Hydroxychloroquine Mefloquine Artemether/Lumefantrine
Aralen Plaquenil Lariam Coartem
Tier 2 Tier 2 Tier 2 PA Tier 2 Tier 2
Atovaquone/Proguanil Primaquine Pyrimethamine Quinine Sulfadoxine/Pyrimethamine
Malarone Primaquine Daraprim Qualaquin Fansidar
Quantity Limit: 24 tablets per 30 days
PA (MedImpact)
Antiprotozoal Agents, Miscellaneous Tier 2 Tier 2
7
Quantity Limit: 1 tablet per day; 90 tablets per 365 days
Atovaquone Nitazoxanide
Mepron Alinia
Antituberculosis Agents Tier 1 Tier 1 Tier 1
Ethambutol Isoniazid Pyrazinamide
Myambutol Isoniazid Pyrazinamide 33
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 1 Tier 1 Tier 2 8
Rifampin Rifampin/Isoniazid Rifabutin
Rifadin Rifamate Mycobutin
Antiviral Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 QL Tier 2
Acyclovir Oral Amantadine Famciclovir Ganciclovir Rimantadine Valacyclovir Adefovir Entecavir Lamivudine Oseltamivir
Zovirax Oral Symmetrel Famvir Cytovene Flumadine Valtrex Hepsera Baraclude Epivir HBV Tamiflu
Tier 2 Tier 2 Tier 2 Tier 2 QL Tier 2
Pentamidine, Aerosolized Ribavirin, Aerosolized Telbivudine Valganciclovir HCl Zanamivir
Nebupent Virazole Tyzeka Valcyte Relenza
Quantity Limit on 45mg and 75mg strengths: 10 capsules per Rx; 30mg strength: 20 capsules per Rx; Suspension: 180ml per Rx; 2 Rxs per year
Quantity Limit: 20 blisters per Rx; 2 Rxs per year
Hepatitis C Agents PA Tier 1
Ribavirin
Copegus
PA Tier 1
Ribavirin
Rebetol
PA Tier 2
Boceprevir
Victrelis
PA Tier 2
Peginterferon Alfa-2b
Peg-Intron
PA Tier 2
Telaprevir
Incivek
PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark
HIV Antiviral Agents All oral, non-experimental antiviral agents used for the treatment of AIDS or HIV-related diseases are considered a formulary benefit. Tier 1 Abacavir/Lamivudine Epzicom Tier 1 Didanosine (ddI) Videx EC Tier 1 Saquinavir Invirase Tier 1 Zidovudine (AZT) Retrovir Tier 2 Abacavir Ziagen Tier 2 Amprenavir Agenerase Tier 2 Atazanavir Reyataz Tier 2 Darunavir Prezista Tier 2 Delavirdine Rescriptor
34
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 2 Tier 2 Tier 2 Tier 2
Didanosine (ddI) Efavirenz Emtricitabine Emtricitabine/Relpivirine/ Tenofovir Emtricitabine/Tenofovir Emtricitabine/Tenofovir/Efavir Enfuvirtide Etravirine Fosamprenavir Indinavir Lamivudine (3TC) Lopinavir/Ritonavir Maraviroc Nelfinavir Nevirapine Nevirapine Raltegravir Rilpivirine Ritonavir Saquinavir Stavudine (d4T) Tenofovir Tipranavir Zalcitabine (ddC) Zidovudine/Lamivudine Zidovudine/Lamivudine/ Abacavir
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 10
Videx Sustiva Emtriva Complera Truvada Atripla Fuzeon Intelence Lexiva Crixivan Epivir Kaletra Selzentry Viracept Viramune Viramune XR Isentress Edurant Norvir Fortovase Zerit Viread Aptivus Hivid Combivir Trizivir
Specialty Pharmacy - Caremark
Antiviral Agents, Monoclonal Antibodies PA $0 Co-payment
11
Dapsone
PA (Caremark) Specialty Pharmacy - Caremark
Dapsone
Periodontal Collagenase Inhibitors Tier 1 Tier 2
5.00
Synagis
Leprostatic Agents Tier 1
12
Palivizumab
Doxycycline Hyclate Doxycycline Hyclate
Periostat Oraxyl
Antineoplastic and Immunosuppressant Agents Antineoplastic Agents All oral, non-experimental antineoplastic are considered a formulary benefit. Tier 1 Tier 1 Tier 1
Anastrozole Bicalutamide Cyclophosphamide
Arimidex Casodex Cytoxan 35
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 PA Tier 1 Tier 1 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 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Etoposide Exemestane Flutamide Hydroxyurea Hydroxyurea Letrozole Leuprolide Acetate
Vepesid Aromasin Eulexin Droxia Hydrea Femara Lupron
Megestrol Mercaptopurine Methotrexate Paclitaxel Tamoxifen Citrate Abiraterone Altretamine Bexarotene Busulfan Capecitabine Chlorambucil Dasatinib Erlotinib Estramustine Everolimus Everolimus Fludarabine Gefitinib Imatinib Mesylate Lapatinib Lenalidomide Lomustine Melphalan Mesna Mitotane Nilotinib Nilutamide Pazopanib Peginterferon Alfa-2b Procarbazine Sorafenib Sunitinib Temozolomide Testolactone Thalidomide Thioguanine Topotecan Toremifene Tretinoin
Megace Purinethol Rheumatrex Taxol Nolvadex Zytiga Hexalen Targretin Myleran Xeloda Leukeran Sprycel Tarceva Emcyt Afinitor Zortress Oforta Iressa Gleevec Tykerb Revlimid Ceenu Alkeran Mesnex Lysodren Tasigna Nilandron Votrient Sylatron Matulane Nexavar Sutent Temodar Teslac Thalomid Thioguanine Hycamtin Fareston Vesanoid
PA (Caremark) Specialty Pharmacy - Caremark
Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark
Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark
Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark
36
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 2 Tier 2 $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment PA $0 Co-payment
Vandetanib Vorinostat Azacitidine Bendamustine Bevacizumab Bortezomib Cabazitaxel Decitabine Docetaxel Eribulin Goserelin Acetate
Vandetanib Zolinza Vidaza Treanda Avastin Velcade Jevtana Dacogen Taxotere Halaven Zoladex
$0 Co-payment $0 Co-payment PA $0 Co-payment
Ipilimumab Ixabepilone Leuprolide Acetate
Yervoy Ixempra Eligard
PA $0 Co-payment
Leuprolide Acetate
Lupron Depot
Levoleucovorin Ofatumumab Panitumumab Rituximab Romidepsin Temozolomide Temsirolimus Topotecan Trastuzumab Valrubicin
Fusilev Arzerra Vectibix Rituxan Istodax Temodar Injection Torisel Hycamtin Injection Herceptin Valstar
$0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment 2
3
Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy Caremark Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark
Immunomodulator Injectable Agents PA $0 Co-payment
Abatacept
Orencia
PA $0 Co-payment
Alefacept
Amevive
PA $0 Co-payment
Tocilizumab
Actemra
PA $0 Co-payment
Ustekinumab
Stelara
PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark
Immunosuppressant Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2
Azathioprine Cyclosporine Cyclosporine Leucovorin Mycophenolate Tacrolimus Anhydrous Mycophenolate DR
Imuran Neoral Sandimmune Leucovorin Cellcept Prograf Myfortic 37
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 2 $0 Co-payment 4
Sirolimus Aldesleukin
Rapamune Proleukin
Specialty Pharmacy - Caremark
Miscellaneous Injectable Agents PA Tier 2
Interferon Alfa 2b
Intron A
PA Tier 2
Interferon Alfacon-1
Infergen
5
PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark
Multiple Sclerosis Agents PA Tier 2
Dalfampridine
Ampyra
SC Tier 2
Fingolimod
Gilenya
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 PA $0 Co-payment
Glatiramer Interferon Beta-1a Interferon Beta-1a Interferon Beta-1b Interferon Beta-1b Natalizumab
Copaxone Avonex Rebif Betaseron Extavia Tysabri
99
PA (Caremark) Specialty Pharmacy Caremark PA (Network Health) if Step Care not met; Quantity Limit: 30 tablets per 30 days Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy Caremark
Immune Globulin Agents PA $0 Co-payment
Immune Globulin, Subcutaneous
Hizentra
PA $0 Co-payment
Immune Globulin, Subcutaneous
Vivaglobin
6.00
PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark
Respiratory/EENT Agents
1
Antihistamine Agents Sedating Antihistamine Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Chlorpheniramine Clemastine Fumarate Cyproheptadine Dexchlorpheniramine Diphenhydramine Hydroxyzine Hydroxyzine Pamoate Promethazine
Chlorpheniramine OTC Tavist Periactin Dexchlorpheniramine Benadryl Atarax Vistaril Phenergan
Nonsedating Antihistamine Agents PA PA PA PA
Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2
Cetirizine Cetirizine Fexofenadine Loratadine Desloratadine Fexofenadine Suspension
Zyrtec OTC Zyrtec Rx Allegra Tablets Loratadine OTC Clarinex Syrup, Tablets Allegra Suspension
PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) 38
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
PA Tier 2
Levocetirizine
Xyzal
PA (MedImpact)
Nasal Antihistamine Tier 1 2
Azelastine HCl
Antihistamine/Decongestant Combination Agents Antihistamine/Decongestant Agents Brompheniramine/ Pseudoephedrine Brompheniramine/ Pseudoephedrine Cetirizine/Pseudoephedrine Cetirizine/Pseudoephedrine Chlorpheniramine/ Phenylephrine Chlorpheniramine/ Pseudoephedrine Fexofenadine/Pseudoephedrine Fexofenadine/Pseudoephedrine Guaifenesin/Pseudoephedrine Guaifenesin/Pseudoephedrine Loratadine/Pseudoephedrine Promethazine/Phenylephrine Acrivastine/Pseudoephedrine Desloratadine/Pseudoephedrine
Tier 1 Tier 1 Tier 1 PA Tier 1 Tier 1 Tier 1 PA Tier 1 PA Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 PA Tier 2 PA Tier 2 3
Astelin
Bromfenex Bromfenex PD Zyrtec-D OTC Zyrtec-D Rx Rynatan
PA (MedImpact)
Deconamine SR Allegra-D 12 Hour Allegra-D 24 Hour Guaifed-PD Guaifen PSE Claritin-D OTC Promethazine VC Semprex-D Clarinex-D 12 hour and 24-hour
PA (MedImpact) PA (MedImpact)
PA (MedImpact) PA (MedImpact)
Antitussive Agents Non-narcotic Antitussive Agents Tier 1 Tier 1 Tier 1
Benzonatate Guaifenesin/Dextromethorphan Promethazine/Dextromethorphan
Benzonatate Tussin DM Phenergan w/Dextromethorphan
Narcotic Antitussive Agents Tier 1 Tier 1
Guaifenesin/Codeine Guaifenesin/Codeine/ Pseudoephedrine Guaifenesin/Hydrocodone Hydrocodone/Chlorpheniramine Hydrocodone/Homatropine Hydrocodone/Phenylephrine/ Chlorpheniramine Promethazine/Codeine Promethazine/Phenylephrine/ Codeine
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 5
Guaifenesin w/ Codeine Cheratussin DAC Vi-Q-Tuss Tussionex Tussigon Histinex HC Phenergan/Codeine Phenergan VC/Codeine
Bronchodilating Agents Inhaled Anticholinergic Agents Tier 1
Ipratropium
Atrovent Inhalation Solution 39
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 2 Tier 2
Ipratropium Tiotropium
Atrovent HFA Spiriva
Inhaled Sympathomimetic (Adrenergic) Agents Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 PA Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Albuterol/Ipratropium Albuterol HFA Inhaler Albuterol HFA Inhaler Albuterol HFA Inhaler Albuterol/Ipratropium Budesonide/Formoterol Fluticasone/Salmeterol Fluticasone/Salmeterol Formoterol Formoterol Levalbuterol Levalbuterol HFA Metaproterenol Mometasone/Formoterol Pirbuterol Acetate Salmeterol
DuoNeb ProAir HFA Proventil HFA Ventolin HFA Combivent Symbicort Advair Diskus Advair HFA Foradil Perforomist Xopenex Xopenex HFA Alupent Dulera Maxair Autohaler Serevent Diskus
PA (MedImpact)
Oral Sympathomimetic (Adrenergic) Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 6
Albuterol Albuterol E.R. Metaproterenol Oral Midodrine Terbutaline Sulfate
Expectorant Agents Tier 1 Tier 1 Tier 1
7
Guaifenesin Guaifenesin/Phenylephrine Potassium Iodide
Guaifenesin Entex LA SSKI
Mucolytic Agents Tier 1 Tier 2
8
Albuterol VoSpire ER Metaproterenol Proamatine Brethine
Acetylcysteine Dornase Alpha
Mucomyst Pulmozyme
Specialty Pharmacy - Caremark
Eye, Ear, Nose, and Throat (EENT) Preparations Carbonic Anhydrase Inhibitor Agents Tier 1 Tier 1 Tier 1
Acetazolamide Acetazolamide SA Methazolamide
Diamox Diamox Sequels Neptazane
Local Anesthetic Agents Tier 1 Tier 1 Tier 1 Tier 1
Benzocaine Benzocaine/Antipyrine Otic Lidocaine, Viscous Triamcinolone 0.1% Paste
Oticaine A-B Otic Viscous Xylocaine Kenalog In Orabase 40
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Ophthalmic Antibiotic Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Bacitracin Ciprofloxacin Erythromycin Base Gentamicin Levofloxacin Neomycin/Bacitracin/
Bacitracin Ciloxan Ilotycin Garamycin Quixin Neosporin Ophth. Ointment
Tier 1
Neomycin/Bacitracin/ Polymyxin/HC Neomycin/Polymyxin/ Dexamethasone Neomycin/Polymyxin/ Gramicidin Neomycin/Polymyxin/ Hydrocortisone Ofloxacin Polymyxin/Bacitracin Polymyxin/Trimethoprim Tobramycin Solution Tobramycin/Dexamethasone Azithromycin Besifloxacin Ciprofloxacin Gatifloxacin 0.3% Gatifloxacin 0.5% Gentamicin/Prednisolone Levofloxacin Moxifloxacin Neomycin/Polymyxin/ Prednisolone Tobramycin Ointment Tobramycin/Dexamethasone Tobramycin/Loteprednol
Cortomycin Ointment
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 QL Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 QL Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 QL Tier 2
Maxitrol Neosporin Ophth. Solution Cortisporin Ophthalmic Ocuflox Polysporin Ophthalmic Polytrim Tobrex Tobradex Suspension AzaSite Besivance Ciloxan Ointment Zymar Zymaxid Pred-G Iquix Vigamox Poly-Pred Tobrex Ointment Tobradex Ointment Zylet
Quantity Limit: 2.5ml per Rx
Quantity Limit: 5ml per 30 days
Quantity Limit: 5ml per 30 days
Ophthalmic Anti-inflammatory Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Dexamethasone 0.1% Solution Diclofenac Sodium Fluorometholone Fluorometholone Flurbiprofen Sodium Ketorolac 0.4% Ketorolac 0.5% Prednisolone Acetate Prednisolone Acetate 1% Suspension Bromfenac Dexamethasone 0.05% Ointment
Tier 2 Tier 2
Dexasol Voltaren Eflone FML Ocufen Acular LS Acular Omnipred Pred Forte Xibrom Decadron 41
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Dexamethasone 0.1% Suspension Difluprednate Fluorometholone Fluorometholone Fluorometholone 0.1% Suspension Ketorolac 0.5% Loteprednol 0.2% Loteprednol 0.5% Nepafenac Prednisolone Acetate Prednisolone Phosphate 0.125% Rimexolone
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Maxidex Durezol FML Forte FML SOP Ointment Flarex Acular PF Alrex Lotemax Nevanac Pred Mild Inflamase Mild Vexol
Ophthalmic Antiviral Agents Tier 1
Trifluridine
Viroptic
Ophthalmic Beta Blockers Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2
Betaxolol Carteolol Levobunolol Metipranolol Timolol Timolol Betaxolol Timolol
Betoptic Ocupress Betagan Optipranolol Timoptic Timoptic-XE Betoptic S Betimol
Ophthalmic Miotic Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Brimonidine Dorzolamide Dorzolamide/Timolol Pilocarpine Brimonidine Brimonidine 0.2%/Timolol 0.5% Brinzolamide Carbachol Demecarium Dipivefrin Echothiophate Iodide Pilocarpine 4% Gel
Alphagan 0.15% and 0.2% Trusopt Cosopt Pilocar Alphagan P 0.1% Combigan Azopt Isopto Carbachol Humorsol Propine Phospholine Iodide Pilopine HS
Ophthalmic Mydriatic Agents Tier 1 QL Tier 1 Tier 1 Tier 1 QL Tier 2
Atropine Sulfate Cyclopentolate Homatropine 5% Solution Tropicamide Scopolamine
Isopto Atropine Cyclogyl Isopto Homatropine Mydriacyl Isopto Hyoscine
Quantity Limit: 2ml per 30 days
Quantity Limit: 5ml per 30 days
42
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Ophthalmic Sulfonamide Agents Tier 1 Tier 1
Sulfacetamide 10% Sulfacetamide 10%/ Prednisolone 0.25% Sulfacetamide 10%/Fluorometholone 0.1% Sulfacetamide 10%/Prednisolone 0.2%
Tier 2 Tier 2
Bleph-10 Vasocidin FML-S Blephamide
Ophthalmic Anti-allergic Agents PA Tier 1 Tier 1 PA Tier 1 Tier 1 PA Tier 2 PA Tier 2 PA Tier 2 PA Tier 2 PA Tier 2 PA Tier 2 PA Tier 2
Azelastine HCl Cromolyn Ophthalmic Solution Epinastine Ketotifen Bepotastine Emedastine Lodoxamide Nedocromil Olopatadine 0.1% Olopatadine 0.2% Pemirolast
Optivar Crolom Elestat Zaditor (OTC) Bepreve Emadine Alomide Alocril Patanol Pataday Alamast
PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact)
Ophthalmic Prostaglandin Agonists Tier 2 Tier 2 Tier 2 Tier 2
Bimatoprost Latanoprost Travoprost Travoprost
Lumigan Xalatan Travatan Travatan Z
Ophthalmic Miscellaneous Agents Cyclosporine Ophthalmic Emulsion
QL Tier 2
Restasis
Quantity Limit: 60 vials per Rx
Otic Anti-infective Agents Tier 1 Tier 1 Tier 1
Acetic Acid Acetic Acid Acetic Acid 2%/ Hydrocortisone 1% Hydrocortisone/Neomycin/ Polymyxin Ofloxacin Ciprofloxacin/Dexamethasone Ciprofloxacin/Hydrocortisone Colistin/Neomycin/ Hydrocortisone Hydrocortisone/Neomycin/ Polymyxin/Thonzonium
Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 9
Domeboro Vosol Vosol HC Cortisporin Floxin Otic Ciprodex Cipro HC Coly-Mycin S Otic Cortisporin-TC
Inhaled Anti-inflammatory Agents Inhaled Adrenal Corticosteroid Agents Budesonide Inhalation Suspension
Tier 1
Pulmicort Respules 0.25mg/2ml and 0.5mg/2ml
43
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 2 Tier 2
Beclomethasone Inhaler Budesonide Inhalation Suspension Budesonide Inhaler Ciclesonide Fluticasone Inhaler Fluticasone Powder Mometasone Triamcinolone Inhaler
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Qvar Pulmicort Respules 1mg/2ml Pulmicort Alvesco Flovent HFA Flovent Diskus Asmanex Azmacort
Nasal Inhaled Corticosteroid Agents
PA PA PA PA PA PA
Flunisolide Fluticasone Propionate Triamcinolone Acetonide, Nasal Beclomethasone, Nasal Budesonide Ciclesonide Fluticasone Furoate Mometasone
Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Nasarel Flonase Nasacort AQ Beconase AQ Rhinocort Aqua Omnaris Veramyst Nasonex
PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact)
Mast Cell Stabilizer
10
Tier 1
Cromolyn Sodium
Intal Solution for Inhalation
Tier 2
Cromolyn Sodium
Intal Inhaler
Leukotriene Receptor Antagonists Tier 1 SC Tier 2
11
Zafirlukast Montelukast
Chlorhexidine Gluconate Cevimeline Cromolyn Oral Solution Fluocinolone Pilocarpine Omalizumab
Peridex Evoxac Gastrocrom DermOtic Salagen Xolair
PA (Caremark) Specialty Pharmacy - Caremark
Miscellaneous Respiratory Aids $0 Co-payment $0 Co-payment QL $0 Co-payment
13
PA (MedImpact) If Step Care Not Met
Miscellaneous EENT Agents Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 PA $0 Co-payment
12
Accolate Singulair
Peak Flow Meters Sodium Chloride Spacers
Peak Flow Meters Sodium Chloride Spacers
Quantity Limit: 2 spacers per 365 days
Respiratory Smooth Muscle Relaxant Agents Tier 1
Caffeine Citrate
Cafcit 44
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 1 Tier 1 7.00 1
Theophylline SR Theophylline SR
Theochron Uniphyl
Diabetic and Thyroid Agents Diabetic Agents Sulfonylureas Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Chlorpropamide Glipizide Glipizide ER Glyburide Glyburide Tolazamide Tolbutamide
Diabinese Glucotrol Glucotrol XL Diabeta Micronase Tolinase Orinase
Nonsulfonylureas Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 SC Tier 2
Acarbose Glimepiride Metformin Metformin Nateglinide Glucagon Metformin Miglitol Pioglitazone Repaglinide Rosiglitazone Sitagliptin
Precose Amaryl Glucophage Glucophage XR Starlix Glucagon Riomet Glyset Actos Prandin Avandia Januvia
PA (MedImpact) If Step Care Not Met; Quantity Limit: 30 tablets per 30 days
Combination Diabetic Agents Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 SC Tier 2
2
Glipizide/Metformin Glyburide/Metformin Pioglitazone/Glimepiride Pioglitazone/Metformin Pioglitazone/Metformin Repaglinide/Metformin Rosiglitazone/Glimepiride Rosiglitazone/Metformin Sitagliptin/Metformin
Metaglip Glucovance Duetact ActoPlus Met Actoplus Met XR Prandimet Avandaryl Avandamet Janumet
PA (MedImpact) If Step Care Not Met; Quantity Limit: 60 tablets per 30 days
Insulin Agents Tier 1 Tier 1 Tier 2 Tier 2
Insulin, Human Insulin, Human Insulin Aspart Insulin Aspart Protamine/Aspart
Humulin Novolin NovoLog NovoLog Mix 45
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 3
Insulin Detemir Insulin Glargine Human Insulin Glulisine Insulin Lispro Insulin Lispro Protamine/Lispro
Miscellaneous Injectable Diabetic Agents Tier 2 Tier 2 Tier 2
4
Exenatide Liraglutide Pramlintide
Levothyroxine Liothyronine Thyroid, Pork Levothyroxine Levothyroxine Liotrix Thyroid, Desiccated
Unithroid Cytomel Nature-Throid Levoxyl Synthroid Thyrolar Armour Thyroid
Antithyroid Agents Tier 1 Tier 1 Tier 1
99
Byetta Victoza Symlin
Thyroid Agents Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2
5
Levemir Lantus Apidra Humalog Humalog Mix
Calcitriol Methimazole Propylthiouracil
Rocaltrol Tapazole Propylthiouracil
Diabetic Supplies $0 Co-payment
Syringes, Needles, and Pen Needles
Insulin Syringes, Needles and Pen Needles
Includes products from Becton-Dickinson, Novo Nordisk and others. Quantity Limit: 2 meters per year; Abbott Diabetes Care and Lifescan products preferred Quantity Limit: 2 meters per year Quantity Limit: 2 meters per year Quantity Limit: 2 meters per year
Blood Glucose Meters QL $0 Co-payment
Blood Glucose Meters
Blood Glucose Meters
QL $0 Co-payment QL $0 Co-payment QL $0 Co-payment
Blood Glucose Meters Blood Glucose Meters Blood Glucose Meters
Freestyle One Touch Precision
Blood Glucose Testing Strips QL $0 Co-payment
Blood Glucose Test Strips
Blood Glucose Testing Strips
QL $0 Co-payment
Blood Glucose Test Strips
Freestyle
QL $0 Co-payment
Blood Glucose Test Strips
One Touch
Quantity Limit: 150 strips per 30 days; Abbott Diabetes Care and Lifescan products preferred Quantity Limit: 150 strips per 30 days Quantity Limit: 150 strips per 30 days
46
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
QL $0 Co-payment
Blood Glucose Test Strips
Precision
QL $0 Co-payment
Blood Ketone Test Strips
Precision Xtra Test Strips
8.00
Quantity Limit: 150 strips per 30 days Quantity Limit: 20 strips per 30 days
Endocrine and Metabolic Agents
1
Oral Adrenocorticosteroid Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2
2
Cortisone Acetate Dexamethasone Fludrocortisone Acetate Hydrocortisone Oral Methylprednisolone Methylprednisolone Prednisolone Prednisolone Prednisone Aminoglutethimide Betamethasone Oral Dexamethasone Prednisolone
Cortisone Decadron Florinef Cortef Medrol Medrol Dosepak Pediapred Prelone Orasone Cytadren Celestone DexPak Orapred ODT
Excludes Flo-Pred
Androgen Agents Tier 1 PA Tier 1 PA Tier 1 PA Tier 1 Tier 2 PA Tier 2 PA Tier 2 PA Tier 2 PA Tier 2 PA Tier 2 PA Tier 2 PA Tier 2
Danazol Oxandrolone Testosterone Cypionate Testosterone Ethanthate Fluoxymesterone Methyltestosterone Oxymetholone Testosterone Buccal Testosterone Gel Testosterone Gel Testosterone Pellets Testosterone Topical
PA Tier 2 PA Tier 2
Testosterone Topical Solution Testosterone Transdermal
3
Danocrine Oxandrin Depo-Testosterone Delatestryl Halotestin Methitest Anadrol-50 Striant Androgel Fortesta Testopel First-Testosterone Cream & Ointment Axiron Androderm
PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact)
Bisphosphonate Agents
PA PA PA PA PA
Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Alendronate Etidronate Pamidronate Disodium Alendronate/Cholecalciferol Ibandronate Risedronate Risedronate, Delayed-Release Risedronate/Calcium
Fosamax Didronel Aredia Fosamax-D Boniva Actonel Atelvia Actonel with Calcium
PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) PA (MedImpact) 47
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
PA Tier 2 PA $0 Co-payment
Tiludronate Zoledronic Acid
Skelid Reclast 5mg/100ml
PA $0 Co-payment
Zoledronic Acid
Zometa 4mg/5ml
4
Miscellaneous Agents for Osteoporosis Tier 1 Tier 2 PA Tier 2
Calcitonin Salmon Calcitonin Salmon Teriparatide
Miacalcin Nasal Spray Miacalcin Injection Forteo
PA $0 Co-payment
Denosumab
Prolia
PA $0 Co-payment
Denosumab
Xgeva
9.00 1
PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark
Hormone and Contraceptive Agents Estrogen Agents Esterified Estrogens/Methyltestosterone Esterified Estrogens/Methyltestosterone Estradiol Estradiol Estradiol, Transdermal Estradiol, Transdermal Estradiol/Norethindrone Estropipate Estropipate Conjugated Estrogens Estradiol Estradiol, Transdermal Estradiol, Transdermal Estradiol, Transdermal Estradiol, Vaginal Ring Estradiol, Vaginal Ring Estradiol/Levonorgestrel Patch Estradiol/Norethindrone Estradiol/Norethindrone Estrogen/Medroxyprogesterone Estrogen/Medroxyprogesterone Estrogens, Esterified
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 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 2 Tier 2 Tier 2 2
PA (MedImpact) PA (Network Health) Specialty Pharmacy - Caremark PA (Network Health) Specialty Pharmacy - Caremark
Estratest Estratest H.S. Estrace Estradiol Climara Vivelle Activella Ogen Ortho-Est Premarin Vagifem Alora Estraderm Vivelle-Dot Estring Femring Climara Pro Combipatch Femhrt Premphase Prempro Menest
Estrogen Agonist-antagonists Tier 2
Raloxifene
Evista
3
48
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Human Growth Hormones
4
PA Tier 2
Somatropin
Genotropin
PA Tier 2
Somatropin
Humatrope
PA Tier 2
Somatropin
Norditropin
PA Tier 2
Somatropin
Nutropin
PA Tier 2
Somatropin
Nutropin AQ
PA Tier 2
Somatropin
Saizen
PA Tier 2
Somatropin
Serostim
PA Tier 2
Somatropin
Tev-Tropin
Growth Hormone Receptor Antagonist PA Tier 2
5
6
PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark Preferred Product - PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Caremark) Specialty Pharmacy - Caremark PA (Network Health); Specialty Pharmacy - Caremark Preferred Product - PA (Caremark) Specialty Pharmacy - Caremark
Pegvisomant
Somavert
PA (Network Health) Specialty Pharmacy - Caremark
PA (Network Health) Specialty Pharmacy - Caremark PA (Network Health) Specialty Pharmacy - Caremark PA (Network Health) Specialty Pharmacy - Caremark
Somatostatin Analogs PA Tier 1
Octreotide IR
Sandostatin
PA Tier 2
Lanreotide
Somatuline Depot
PA $0 Co-payment
Octreotide LAR Depot
Sandostatin LAR
Oral Contraceptive Agents Monophasic Oral Contraceptives $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment
Desogestrel/Ethinyl Estradiol Desogestrel/Ethinyl Estradiol Drosperinone/Ethinyl Estradiol Drosperinone/Ethinyl Estradiol Ethynodiol/Ethinyl Estradiol Levonorgestrel/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol
Desogen Ortho-Cept Yasmin Yaz Zovia Levora Brevicon Junel Levlite Loestrin Modicon Norinyl 1/35 Ortho Novum 1/35 Ortho Novum 1/50 Ovcon-35 49
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
$0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment
Norethindrone/Ethinyl Estradiol/Fe Norethindrone/Ethinyl Estradiol/Fe Norethindrone/Ethinyl Estradiol/Fe Norethindrone/Mestranol Norgestimate/Ethinyl Estradiol Norgestimate/Ethinyl Estradiol Norgestrel/Ethinyl Estradiol Norgestrel/Ethinyl Estradiol
Femcon Fe Generess Fe Loestrin Fe
Excludes Loestrin 24 Fe
Norinyl 1/50 Ortho Cyclen Sprintec Low-Ogestrel Ogestrel
Biphasic Oral Contraceptives $0 Co-payment $0 Co-payment
Desogestrel/Ethinyl Estradiol Norgestimate/Ethinyl Estradiol
Mircette Ortho Novum 10/11
Triphasic Oral Contraceptives $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment
Desogestrel/Ethinyl Estradiol Levonorgestrel/Ethinyl Estradiol Levonorgestrel/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol Norethindrone/Ethinyl Estradiol/Fe Norgestimate/Ethinyl Estradiol
Cyclessa Preven Trivora Necon Nortrel Ortho Novum 7/7/7 Tri-Norinyl Estrostep Fe Ortho Tri-Cyclen
Excludes Ortho-Tri-Cyclen Lo
Extended-cycle Oral Contraceptives $0 Co-payment $0 Co-payment
Levonorgestrel/Ethinyl Estradiol Levonorgestrel/Ethinyl Estradiol
Seasonale Seasonique
Progestin-only Agents $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment 7
Norethindrone Norethindrone Norethindrone Norethindrone
Camila Nor QD Nora-BE Ortho Micronor
Contraceptive Agents, Other $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment $0 Co-payment
Diaphragms Etonogestrel/Ethinyl Estradiol Vaginal Ring Levonorgestrel Levonorgestrel Medroxyprogesterone Medroxyprogesterone Norelgestromin/ Ethinyl Estradiol Ulipristal
Ortho All Flex Nuvaring Plan B Plan B One-Step Depo-Provera Depo-Subq Provera Ortho Evra Ella 50
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
8
Oxytocic Agents Tier 1 9
Methylergonovine Maleate
Pituitary Agents Tier 1
10
Desmopressin
1
Medroxyprogesterone Norethindrone Acetate Progesterone Vaginal Gel Progesterone
Urinary Anti-infective Agents Meth/Me Blue/BA/Salicy/ATP/Hyos Meth/Sod Phos/Meth Blue/Hyos Methenamine Mandelate Nitrofurantoin Macrocrystals Nitrofurantoin Macrocrystals Trimethoprim Meth/Me Blue/BA/Salicy/ATP/Hyos Nitrofurantoin Oral Suspension Trimethoprim
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2
Citric Acid/K-Citrate Citric Acid/K-Citrate/Na-Citrate Citric Acid/K-Citrate/Na-Citrate Citric Acid/Na-Citrate
Urogesic-Blue Mandelamine Macrobid Macrodantin Proloprim Prosed/DS Furadantin Primsol
Polycitra-K Solution Polycitra Syrup Polycitra-LC Solution Bicitra Solution
Urinary Antispasmodic Agents Tier 1 Tier 2
4
Urised
Urinary pH Modifiers Tier 1 Tier 1 Tier 1 Tier 1
3
Provera Aygestin Prochieve Prometrium
Genitourinary Agents
Tier 1
2
DDVAP
Progestin Agents Tier 1 Tier 1 Tier 1 Tier 2
10.00
Methergine
Phenazopyridine Pentosan
Pyridium Elmiron
Genitourinary Smooth Muscle Relaxant Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2
Flavoxate Oxybutynin Oxybutynin ER Trospium Darifenacin Fesoterodine
Urispas Ditropan Ditropan XL Sanctura Enablex Toviaz 51
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 5
Oxybutynin Gel Oxybutynin Transdermal Patch Solifenacin Tolterodine Tolterodine Trospium XR
Urinary Cholinergic Agents Tier 1
6
Bethanechol
Urecholine
Benign Prostatic Hypertrophy Agents PA Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 PA Tier 2 PA Tier 2 PA Tier 2
7
Alfuzosin Doxazosin Finasteride Tamsulosin Terazosin Doxazosin XL Dutasteride Dutasteride/Tamsulosin Silodosin
Uroxatral Cardura Proscar Flomax Hytrin Cardura XL Avodart Jalyn Rapaflo
PA (MedImpact)
PA (MedImpact) PA (MedImpact) PA (MedImpact)
Impotency Agents QL Tier 2
Alprostadil Injection
Caverject
QL QL QL QL QL
Alprostadil Injection Alprostadil Suppository Sildenafil Citrate Tadalafil Vardenafil
EDEX MUSE Viagra Cialis Levitra
Quantity Limit: 6 ampules/vials per 30 days Quantity Limit: 6 vials per 30 days Quantity Limit: 6 pellets per 30 days Quantity Limit: 4 tablets per 30 days Quantity Limit: 4 tablets per 30 days Quantity Limit: 4 tablets per 30 days
Adapalene
Differin 0.1% Cream/Gel
PA (MedImpact) If Step Care Not Met
Tier 1
Benzoyl Peroxide
Benzoyl Peroxide Cleanser
Tier 1
Benzoyl Peroxide
Benzoyl Peroxide Gel
Tier 1
Benzoyl Peroxide
Benzoyl Peroxide Lotion
Includes 2.5%, 5%, and 10% generic products Includes 2.5%, 5%, and 10% generic products Includes 2.5%, 5%, and 10% generic products
Clindamycin Lotion/Gel Clindamycin Solution Clindamycin/Benzoyl Peroxide Erythromycin Topical Erythromycin/Benzoyl Peroxide
Clindamycin Lotion/Gel Clindamycin Solution Benzaclin Erythromycin Topical Erythromycin/ Benzoyl Peroxide
11.00 1
Gelnique Oxytrol Vesicare Detrol Detrol LA Sanctura XR
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Topical/Mucous Membrane Agents Anti-acne Agents
SC Tier 1
Tier 1 Tier 1 PA Tier 1 Tier 1 QL Tier 1
Excludes medicated swabs PA (MedImpact) Excludes medicated swabs Quantity Limit: 23gm per 30 days 52
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
2
Tier 1 Tier 1 PA Tier 1 SC Tier 2
Sulfacetamide/Sulfur, Lotion Sulfacetamide/Sulfur, Wash Tretinoin Adapalene
Sulfatol Sulfacetamide/Sulfur Tretinoin Differin 0.3% Gel
QL Tier 2 PA Tier 2
Azelaic Acid Dapsone Gel
Azelex 20% Cream Aczone
Excludes medicated swabs PA (MedImpact) age > 26 years PA (MedImpact) If Step Care Not Met Quantity Limit: 30gm per Rx PA (MedImpact)
Miscellaneous Skin/Mucous Membrane Agents Tier 1
Aluminum Chloride Hexahydrate
Drysol Lac-Hydrin Dovonex Ointment Dovonex Solution Efudex Aldara Amnesteem Claravis Sotret Allanderm-T
Tier 1 Tier 1 QL Tier 2
Ammonium Lactate Calcipotriene Calcipotriene Fluorouracil Imiquimod Isotretinoin Isotretinoin Isotretinoin Trypsin/Balsam Peru/ Castor Oil Ointment Trypsin/Balsam Peru/ Castor Oil Spray Urea 40% Cream, Lotion Urea 50% Cream, Ointment Acitretin
Tier 2 Tier 2 QL Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 QL Tier 2 QL Tier 2
Anthralin Anthralin Azelaic Acid Becaplermin Bexarotene Calcipotriene Calcitriol Ointment Collagenase Diclofenac 3% Gel
Drithocreme HP 1% Dritho-Scalp 0.5% Finacea 15% Gel Regranex Targretin Gel Dovonex Cream Vectical Santyl Solaraze
QL Tier 2 PA Tier 2 Tier 2 PA Tier 2 SC Tier 2
Doxepin Cream Pimecrolimus Podofilox Tacrolimus Tazarotene
Prudoxin Elidel Condylox Protopic Tazorac
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 PA Tier 1 PA Tier 1 PA Tier 1 Tier 1 Tier 1
Excludes adhesive bandages PA (MedImpact) PA (MedImpact) PA (MedImpact)
Granul-Derm Urea Urea Soriatane
Quantity Limit: 60 capsules per 30 days
Quantity Limit: 50gm per Rx
Quantity Limit: 1 tube per Rx Quantity Limit: 1 tube per Rx; 90-day supply per year Quantity Limit: 45 gm per Rx PA (MedImpact) PA (MedImpact) PA (MedImpact) If Step Care Not Met
Topical Antiseptic QL Tier 2 3
Hexachlorophene
Phisohex
Quantity Limit: 148ml per Rx
Pigmenting and Miscellaneous Agents Tier 2
Methoxsalen
Oxsoralen 53
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
4
Rectal Agents Hydrocortisone 1% Rectal Cream Hydrocortisone 1% Rectal Cream Hydrocortisone 1%/ Pramoxine 1% Cream Hydrocortisone 2.5%/ Pramoxine 1% Cream Hydrocortisone Acetate 2.5% Hydrocortisone 1%/ Pramoxine 1% Foam Hydrocortisone 1%/ Pramoxine 1% Ointment, Lotion Hydrocortisone 2.5%/ Pramoxine 1% Cream, Lotion
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 5
Proctocream HC Analpram HC HC Pramosone Anusol HC 2.5% Proctofoam HC Pramosone Analpram HC
Topical Antibiotic Agents Tier 1 Tier 1 Tier 1 Tier 1 PA Tier 2 Tier 2
Gentamicin Sulfate Metronidazole Cream, Gel Mupirocin Ointment Silver Sulfadiazine Mupirocin Cream Mupirocin Nasal Ointment, Preservative Free Retapamulin
SC Tier 2 6
Proctocort
Garamycin Metronidazole Cream, Gel Bactroban Silvadene Bactroban Cream Bactroban Nasal Altabax
PA (MedImpact)
PA (MedImpact) If Step Care Not Met
Topical Antifungal Agents Ciclopirox Cream, Gel, Suspension Ciclopirox Shampoo Clotrimazole Cream, Solution Clotrimazole Lotion Clotrimazole/ Betamethasone Cream Clotrimazole/ Betamethasone Lotion Econazole Ketoconazole Miconazole Nitrate (OTC) Nystatin Terbinafine (OTC) Triamcinolone/Nystatin Naftifine
Tier 1 PA Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 PA Tier 2
Loprox Cream, Gel, Suspension Loprox Shampoo Lotrimin Cream, Solution Lotrimin Lotion Lotrisone Cream
PA (MedImpact)
Lotrisone Lotion Spectazole Nizoral Miconazole (OTC) Nystatin Terbinafine (OTC) Mycolog II Naftin
PA (MedImpact) 54
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
PA Tier 2 PA Tier 2 7
Sulconazole Terbinafine Spray
Miconazole Terconazole Terconazole Tioconazole Butoconazole
Monistat 3 Terazol-3 Terazol-7 Vagistat-1 Gynazole-1
Vaginal Anti-infective Agents Tier 1 Tier 1 Tier 2
9
PA (MedImpact) PA (MedImpact)
Vaginal Antifungal Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 2
8
Exelderm Lamisil Spray
Clindamycin Metronidazole Sulfanilamide Compound
Cleocin Metrogel-Vaginal AVC Cream
Topical Anti-inflammatory Agents Low Potency Topical Anti-inflammatory Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 PA Tier 2
Alclometasone Desonide Desonide Fluocinolone Hydrocortisone Fluocinolone 0.01% Oil Fluocinolone Shampoo
Aclovate Desowen Tridesilon Synalar Hytone Derma-Smoothe/FS Capex Shampoo
PA (MedImpact)
Medium Potency Topical Anti-inflammatory Agents Tier 1 Tier 1 Tier 1
Betamethasone Dipropionate Betamethasone Dipropionate Betamethasone Valerate 0.1% Desoximetasone 0.05% Cream Desoximetasone 0.05% Gel Fluticasone Cream, Ointment Hydrocortisone Butyrate Hydrocortisone Valerate Mometasone Furoate Triamcinolone Triamcinolone Cream, Lotion, Ointment Triamcinolone Cream, Lotion, Ointment Betamethasone Valerate 0.12% Clocortolone Pivalate Desoximetasone 0.05% Ointment Flurandrenolide Flurandrenolide Fluticasone Lotion
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 PA Tier 2 PA Tier 2 PA Tier 2 PA Tier 2 PA Tier 2 PA Tier 2
Diprosone Maxivate Betamethasone Valerate 0.1% Topicort LP Topicort Cutivate Cream, Ointment Locoid Westcort Elocon Aristocort-A Aristocort Kenalog Luxiq Cloderm Topicort LP
PA (MedImpact) PA (MedImpact) PA (MedImpact)
Cordran Cordran SP Cutivate Lotion
PA (MedImpact) PA (MedImpact) PA (MedImpact) 55
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
PA Tier 2 PA Tier 2
Hydrocortisone Butyrate Triamcinolone Spray
Locoid Lipocream Kenalog Aerosol Spray
PA (MedImpact) PA (MedImpact)
High Potency Topical Anti-inflammatory Agents Tier 1 Tier 1
Amcinonide Betamethasone Dipropionate 0.05% Gel, Ointment Betamethasone Dipropionate 0.05% Lotion Desoximetasone 0.25% Fluocinonide 0.05% Fluocinonide/Emollient
Tier 1 Tier 1 Tier 1 Tier 1
Cyclocort Diprolene Gel, Ointment Diprolene Lotion Topicort Lidex Lidex E
Very High Potency Topical Anti-inflammatory Agents Augmented Betamethasone Dipropionate 0.05% Clobetasol Clobetasol Topical Foam Diflorasone Diacetate Diflorasone Diacetate Diflorasone Diacetate Halobetasol Clobetasol Topical Lotion, Shampoo, Spray Fluocinonide 0.1%
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 PA Tier 2 PA Tier 2 10
Lidocaine 2% Gel Lidocaine 3% Cream, Lotion Lidocaine 4% Injection Lidocaine 5% Ointment Lidocaine Viscous Lidocaine/Prilocaine Lidocaine Medicated Patch
Diclofenac 1% Gel Diclofenac 1.3% Patch
Vanos
PA (MedImpact)
Lidocaine Lidocaine Lidocaine Lidocaine Xylocaine EMLA Lidoderm
Voltaren Gel Flector
PA (MedImpact) PA (MedImpact)
Zovirax Cream Zovirax Ointment Denavir Cream
Quantity Limit: 1 tube per Rx
Topical Antiviral Agents QL Tier 2 Tier 2 Tier 2
13
PA (MedImpact)
Topical Analgesics PA Tier 2 PA Tier 2
12
Temovate Olux Maxiflor Psorcon Psorcon-E Ultravate Clobex
Topical Antipruritic and Local Anesthetic Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2
11
Diprolene AF
Acyclovir Topical Acyclovir Topical Pencyclovir
Topical Miscellaneous Anti-infective Agents Tier 1 Tier 1
Selenium Sulfide 2.5% Sulfacetamide Lotion
Selsun Klaron 56
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Tier 2 14
Anthralin
Scabicide/Pediculicide Agents Tier 1 Tier 1 QL Tier 2 Tier 2 Tier 2
12.00 1
Psoriatec
Lindane Permethrin Benzyl Alcohol 5% Lotion Crotamiton Malathion
Kwell Elimite Ulesfia Eurax Lotion Ovide
Quantity Limit: 12 bottles per Rx
Miscellaneous/Unclassified Agents Electrolyte Agents Sodium Chloride Tier 1
Sodium Chloride
Sodium Chloride
Potassium Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Potassium Chloride 10mEq Potassium Chloride 10mEq Potassium Chloride 10mEq Potassium Chloride 10mEq Potassium Chloride 20mEq Potassium Chloride 8mEq Potassium Chloride 8mEq Potassium Chloride Effervescent Tablets 25mEq Potassium Chloride Effervescent Tablets 50mEq Potassium Chloride Liquid 20mEq Potassium Chloride Powder 20mEq Potassium Citrate
Tier 1 Tier 1 Tier 1 Tier 1
Kaon-Cl 10 K-Dur K-Tabs Micro-K 10 K-Dur Klor-Con 8 Micro-K K-Lyte K-Lyte CL DS KCl K-Lor Urocit-K
Potassium-removing Agents Tier 1
Sodium Polystyrene Sulfonate
Kayexalate
Phosphorus Agents Tier 1 Tier 2 Tier 2
Phosphorus Phosphorus Potassium Phosphate/ Sodium Phosphate Potassium Phosphate/ Sodium Phosphate
Tier 2
K-Phos Neutral K-Phos Original K-Phos M.F. K-Phos No. 2
Phosphate Binders Tier 1 Tier 2 Tier 2 Tier 2 Tier 2
Calcium Acetate Calcium Acetate Lanthanum Sevelamer Carbonate Sevelamer HCl
PhosLo Phoslyra Fosrenol Renvela Renagel
57
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Calcimimetic SC Tier 2
Cinacalcet
Sensipar
PA (Network Health) If Step Care Not Met; Specialty Pharmacy - Caremark
Samsca
Quantity Limit on 15mg strength: 30 tablets per 30 days; Quantity Limit on 30mg strength: 60 tablets per 30 days; Specialty Pharmacy - Caremark
Vasopressin Antagonist QL Tier 2
Tolvaptan
Heavy Metal Antagonist Agents Tier 2 Tier 2 Tier 2
Penicillamine Penicillamine Succimer
Cuprimine Depen Chemet
Vitamin and Fluoride Agents Prenatal Vitamin Agents Tier 1
Prenatal Multivitamins (generic)
Prenatal Vitamins (generic)
Iron Supplements Generic OTC product preferred.
Fluoride Agents Tier 1 Tier 1 Tier 1
Sodium Fluoride (drops and tablets) Luride Sodium Fluoride (cream) Prevident 5000 Plus Sodium Fluoride (gel) Sodium Fluoride
Vitamin A Tier 1
Beta-Carotene
Beta-Carotene
Vitamin B-complex Agents Tier 1 Tier 1 Tier 1
Folic Acid Folic Acid/Multivitamins with Minerals Niacin
Folic Acid Vicon Forte
Vitamin B-12
Cyanocobalamin
Calcitriol Cholecalciferol Ergocalciferol Dihydrotachysterol Doxercalciferol
Rocaltrol Vitamin D Drisdol Hytakerol Hectorol
Niacin
Vitamin B-12 Tier 1
Vitamin D Tier 1 Tier 1 Tier 1 Tier 2 Tier 2
Vitamin K Activity Agents Tier 2
Phytonadione
Mephyton
Miscellaneous Vitamins Folic Acid/ Vitamin-B-Complex w/ C
Tier 1
Nephrocaps
58
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
Folic Acid/ Vitamin B Complex w/C
Tier 2
Nephrocaps QT
Multivitamin Agents Fluoride/Polyvitamins (without iron; drops and tablets) Fluoride/Vitamins A, D, C (with and without iron; drops and tablets)
Tier 1 Tier 1
5
Epinephrine 0.15mg/0.3ml Epinephrine 0.3mg/0.3ml Epinephrine 0.15mg/0.3ml Epinephrine 0.3mg/0.3ml
Disulfiram Acamprosate
Antabuse Campral
Allopurinol Colchicine Colchicine/Probenecid Probenecid Colchicine Febuxostat
Zyloprim Colchicine Col-Benemid Benemid Colcrys Uloric
$0 Co-payment
Influenza Virus Vaccine
Flumist
Covered from September 15th through March 31st for members at least 18 years of age and if administered by a pharmacist at a participating pharmacy
$0 Co-payment
Influenza Virus Vaccine
Influenza Vaccine 2011-2012
Covered from September 15th through March 31st for members at least 18 years of age and if administered by a pharmacist at a participating pharmacy
100
Quantity Limit: a continuous 90-day supply within a 180-day time frame Quantity Limit: a continuous 90-day supply within a 180-day time frame
Quantity Limit: 180 tablets per 30 days
Gout Agents Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 PA Tier 2
10
Epinephrine Syringe Epinephrine Syringe EpiPen Jr EpiPen
Alcohol Deterrent Agents Tier 1 QL Tier 2
7
Tri-Vi-Flor
Emergency Kits Tier 1 Tier 1 Tier 2 Tier 2
6
Poly-Vi-Flor
PA (MedImpact)
Immunization
Tobacco Cessation Agents QL Tier 1
Bupropion SR
Zyban
QL Tier 1
Nicotine, Polacrilex
Commit
59
Network Health Preferred Drug List (Network Health Together and Network Health Forward Plan Type I) For updated information, please visit www.network-health.org or call 888-257-1985.
QL Tier 1
Nicotine, Polacrilex
Nicotine Gum
QL Tier 1
Nicotine, Transdermal
Nicoderm CQ
QL Tier 2
Nicotine, Inhaler
Nicotrol
QL Tier 2
Nicotine, Nasal Spray
Nicotrol NS
QL Tier 2
Varenicline
Chantix
Quantity Limit: a continuous 90-day supply within a 180-day time frame OTC patches covered; Quantity Limit: a continuous 90-day supply within a 180-day time frame Quantity Limit: a continuous 90-day supply within a 180-day time frame Quantity Limit: a continuous 90-day supply within a 180-day time frame Quantity Limit: 60 tablets per 30 days for 24 weeks
60
Index A A-B Otic, 40 Abacavir, 34, 35 Abacavir/Lamivudine, 34 Abatacept, 37 Abilify, 20 Abiraterone, 36 AbobotulinumtoxinA, 18 Abstral Sublingual Tablets, 16 Acamprosate, 59 Acarbose, 45 Accolate, 44 Accupril, 23 Accuretic, 24 Acebutolol, 23 Aceon, 23 Acetazolamide, 40 Acetazolamide SA, 40 Acetic Acid, 43 Acetylcysteine, 40 Aciphex, 29 Acitretin, 53 Aclovate, 55 Acrivastine/Pseudoephedrine, 39 Actemra, 37 Actigall, 30 Actiq Lozenge, 15 Activella, 48 Actonel, 47 Actonel with Calcium, 47 ActoPlus Met, 45 Actoplus Met XR, 45 Actos, 45 Acular, 41, 42 Acular LS, 41 Acular PF, 42 Acyclovir Oral, 34 Acyclovir Topical, 56 Aczone, 53 Adalat, 24 Adalat CC, 24 Adalimumab, 14 Adapalene, 52, 53 Adcirca, 25 Adderall, 21 Adderall XR, 21 Adefovir, 34 Advair Diskus, 40 Advair HFA, 40
Advicor, 26 Afinitor, 12, 36 Agenerase, 34 Aggrenox, 27 Agrylin, 27 Akineton, 18 Alamast, 43 Albendazole, 31 Albenza, 31 Albuterol, 40 Albuterol E.R., 40 Albuterol HFA Inhaler, 40 Albuterol/Ipratropium, 40 Alclometasone, 55 Alcohol Deterrent Agents, 59 Aldactazide, 25 Aldactone, 25 Aldara, 53 Aldesleukin, 38 Aldomet, 24 Alefacept, 37 Alendronate, 47 Alendronate/Cholecalciferol, 47 Alfuzosin, 52 Alinia, 33 Aliskiren, 23, 24, 25 Aliskiren/Amlodipine, 24 Aliskiren/Amlodipine/HCTZ, 24 Aliskiren/HCTZ, 25 Aliskiren/Valsartan, 25 Alkeran, 36 Allanderm-T, 53 Allegra Suspension, 38 Allegra Tablets, 38 Allegra-D 12 Hour, 39 Allegra-D 24 Hour, 39 Allopurinol, 59 Almotriptan, 15 Alocril, 43 Alomide, 43 Alora, 48 Alosetron, 28 Aloxi Injection, 28 Alpha Antagonist Agents, 26 Alphagan 0.15% and 0.2%, 42 Alphagan P 0.1%, 42 Alprazolam, 20 Alprostadil Injection, 52 Alprostadil Suppository, 52 Alrex, 42 Altabax, 8, 54
61
Altace, 23 Altretamine, 36 Aluminum Chloride Hexahydrate, 53 Alupent, 40 Alvesco, 44 Amantadine, 17, 34 Amaryl, 45 Ambien, 21 Ambien CR 12.5mg, 21 Ambien CR 6.25mg, 21 Ambrisentan, 25 Amcinonide, 56 Amebicides, 31 Amerge, 9, 14 Amevive, 37 Amicar, 27 Amiloride, 25 Amiloride/HCTZ, 25 Aminocaproic Acid, 27 Aminoglutethimide, 47 Aminoglycosides, 31 Amiodarone, 22 Amitiza, 30 Amitriptyline, 19 Amlodipine, 23, 25 Amlodipine/Olmesartan, 25 Amlodipine/Valsartan, 25 Amlodipine/Valsartan/HCTZ, 25 Ammonium Lactate, 53 Amnesteem, 53 Amoxapine, 19 Amoxicillin, 30, 32 Amoxil, 32 Ampicillin, 32 Amprenavir, 34 Ampyra, 38 Amturnide, 24 Amylase/Lipase/Protease, 30 Amyotrophic Lateral Sclerosis Agents, 18 Anadrol-50, 47 Anafranil, 19 Anagrelide, 27 Analgesic and Anti-inflammatory Agents, 13 Analpram HC, 54 Anaprox, 13 Anaprox DS, 13 Anastrozole, 35 Androderm, 47 Androgel, 47 Androgen Agents, 47 Angiotensin Converting Enzyme Inhibitor Agents, 23 Angiotensin Receptor Blocker Agents, 23 Anhydrous Morphine, 28 Ansaid, 13
Antabuse, 59 Antara, 26 Anthralin, 53, 57 Anti-anginal and Anti-ischemic Agents, Non-hemodynamic, 28 Anti-arrhythmic Agents, 22 Antibiotic Agents, 31 Anticonvulsant Agents, 16 Antidiarrheal Agents, 28 Anti-emetic Agents, 28 Antifibrinolytic Agents, 27 Antifungal Agents, 33 Antihelmintic Agents, 31 Antihistamine Agents, 38 Antihistamine/Decongestant Agents, 39 Antihistamine/Decongestant Combination Agents, 39 Antihyperlipidemic Agents, 26 Antihyperlipidemic Combination Agents, 26 Antihypertensive Agents, 23 Antihypertensive, Pulmonary Arterial, 25 Anti-inflammatory, Anti-arthritic Agents, Miscellaneous, 13 Anti-inflammatory, Tumor Necrosis Factor Inhibitor, 14 Antimalarial Agents, 33 Antimanic Agents, 20 Antimuscarinic/Antispasmodic Agents, 29 Antineoplastic Agents, 35 Antiparkinsonian Agents, 17 Antiplatelet Agents, 27 Antiplatelet Combination Agents, 27 Antiprotozoal Agents, Miscellaneous, 33 Antipsychotic Agents, 20 Antithyroid Agents, 46 Antituberculosis Agents, 33 Antitussive Agents, 39 Anti-ulcer Agents, 29 Antivert, 28 Antiviral Agents, 34, 35 Antiviral Agents, Monoclonal Antibodies, 35 Anusol HC 2.5%, 54 Anzemet Injection, 28 Anzemet Tablet, 28 Apidra, 46 Apokyn, 12, 18 Apomorphine, 18 Aprepitant, 28 Apresoline, 26 Apriso, 31 Aptivus, 35 Aralen, 33 Aranesp, 12, 27 Arava, 13 Aredia, 47 Aricept, 16 Aricept ODT, 16 Arimidex, 35
62
Aripiprazole, 20 Aristocort, 55 Aristocort-A, 55 Arixtra, 27 Armodafinil, 22 Armour Thyroid, 46 Aromasin, 36 Artane, 18 Artemether/Lumefantrine, 33 Arzerra, 12, 37 Asacol, 30 Asenapine, 20 Asendin, 19 Asmanex, 44 Aspirin/Dipyridamole, 27 Astelin, 39 Atarax, 21, 38 Atazanavir, 34 Atelvia, 47 Atenolol, 23, 24 Atenolol/Chlorthalidone, 24 Ativan, 20 Atomoxetine, 22 Atorvastatin, 26 Atorvastatin/Amlodipine, 26 Atovaquone, 33 Atovaquone/Proguanil, 33 Atripla, 35 Atropine Sulfate, 42 Atrovent HFA, 40 Atrovent Inhalation Solution, 39 Attapulgite, 28 Augmented Betamethasone Dipropionate 0.05%, 56 Augmentin, 32 Augmentin ES, 32 Augmentin XR, 32 Avalide, 8, 25 Avandamet, 45 Avandaryl, 45 Avandia, 45 Avapro, 8, 23 Avastin, 12, 37 AVC Cream, 55 Avelox, 32 Avelox ABC Pack, 32 Avinza, 16 Avodart, 52 Avonex, 12, 38 Axert, 9, 15 Axid, 30 Axiron, 47 Aygestin, 51 Azacitidine, 37 AzaSite, 41
Azathioprine, 13, 37 Azelaic Acid, 53 Azelastine HCl, 39, 43 Azelex 20% Cream, 53 Azilect, 18 Azithromycin, 31, 32, 41 Azmacort, 44 Azopt, 42 Azor, 25 Aztreonam, 32 Azulfidine, 13, 30
B Bacitracin, 41 Baclofen, 18 Bactrim, 33 Bactroban, 54 Bactroban Cream, 54 Bactroban Nasal, 54 Balsalazide, 30 Banzel, 17 Baraclude, 34 Becaplermin, 53 Beclomethasone Inhaler, 44 Beclomethasone, Nasal, 44 Beconase AQ, 44 Belladonna/Phenobarbital, 29 Bellergal S, 29 Benadryl, 38 Benazepril, 23, 24 Benazepril/Amlodipine, 24 Benazepril/HCTZ, 24 Bendamustine, 37 Benemid, 59 Benicar, 8, 23, 25 Benicar HCT, 8, 25 Benign Prostatic Hypertrophy Agents, 52 Bentyl, 29 Benzaclin, 52 Benzocaine, 40 Benzocaine/Antipyrine Otic, 40 Benzodiazepines, 20 Benzonatate, 39 Benzoyl Peroxide, 52 Benzoyl Peroxide Cleanser, 52 Benzoyl Peroxide Gel, 52 Benzoyl Peroxide Lotion, 52 Benztropine, 17 Benzyl Alcohol 5% Lotion, 57 Bepotastine, 43 Bepreve, 43 Besifloxacin, 41 Besivance, 41
63
Beta-Carotene, 58 Betagan, 42 Betamethasone Dipropionate, 55, 56 Betamethasone Dipropionate 0.05% Gel, Ointment, 56 Betamethasone Dipropionate 0.05% Lotion, 56 Betamethasone Oral, 47 Betamethasone Valerate 0.12%, 55 Betapace, 22 Betaseron, 12, 38 Betaxolol, 23, 42 Bethanechol, 52 Betimol, 42 Betoptic, 42 Betoptic S, 42 Bevacizumab, 37 Bexarotene, 36, 53 Biaxin, 31 Biaxin XL, 31 Bicalutamide, 35 Bicillin LA, 32 Bicitra Solution, 51 Biltricide, 31 Bimatoprost, 43 Biperiden, 18 Biphasic Oral Contraceptives, 50 Bisoprolol, 23, 24 Bisoprolol/HCTZ, 24 Bisphosphonate Agents, 47 Bleph-10, 43 Blephamide, 43 Blocadren, 23 Blood Glucose Meters, 46 Blood Glucose Test Strips, 46, 47 Blood Glucose Testing Strips, 46 Blood Ketone Test Strips, 47 Boceprevir, 34 Boniva, 47 Bortezomib, 37 Bosentan, 25 Botox, 18 Bowel Evacuant Agents, 29 Brethine, 40 Brevicon, 49 Brimonidine, 42 Brimonidine 0.2%/Timolol 0.5%, 42 Brinzolamide, 42 Bromfenac, 41 Bromfenex, 39 Bromfenex PD, 39 Bromocriptine, 17 Bronchodilating Agents, 39 Budesonide, 30, 40, 43, 44 Budesonide Inhalation Suspension, 43 Budesonide Inhaler, 44
Budesonide/Formoterol, 40 Bumetanide, 25 Bumex, 25 Buprenorphine, 16 Buprenorphine, Transdermal, 16 Buprenorphine/Naloxone, 16 Bupropion, 19, 59 Bupropion SR, 19, 59 Buspar, 21 Buspirone, 21 Busulfan, 36 Butalbital/APAP, 14, 15 Butalbital/APAP/Caffeine, 14, 15 Butalbital/Aspirin/Caffeine, 14 Butalbital/Aspirin/Codeine, 15 Butoconazole, 55 Butorphanol Tartrate, 16 Butrans, 16 Byetta, 46 Bystolic, 8, 23
C Cabazitaxel, 37 Cabergoline, 17 Caduet, 26 Cafcit, 44 Cafergot, 14 Caffeine Citrate, 44 Calan, 24 Calan SR, 24 Calcimimetic, 58 Calcipotriene, 53 Calcitonin Salmon, 48 Calcitriol, 46, 53, 58 Calcitriol Ointment, 53 Calcium Acetate, 57 Calcium Channel Blocking Agents, 23 Camila, 50 Campral, 59 Canasa, 31 Capecitabine, 36 Capex Shampoo, 55 Capoten, 23 Capozide, 24 Captopril, 23, 24 Captopril/HCTZ, 24 Carafate, 29 Carafate Suspension, 29 Carbachol, 42 Carbamazepine, 16, 17 Carbamazepine XR, 16, 17 Carbatrol, 16 Carbidopa, 18
64
Carbidopa/Levodopa, 18 Carbidopa/Levodopa CR, 18 Carbidopa/Levodopa ODT, 18 Carbonic Anhydrase Inhibitor Agents, 40 Cardene, 24 Cardiac Glycoside Agents, 27 Cardizem, 24 Cardizem CD, 24 Cardizem LA, 24 Cardizem SR, 24 Cardura, 26, 52 Cardura XL, 52 Carisoprodol, 18 Carisoprodol/Aspirin, 18 Carteolol, 42 Cartia XT, 24 Carvedilol, 23 Casodex, 35 Cataflam, 13 Catapres, 24 Catapres-TTS, 24 Caverject, 52 Cayston, 32 Ceclor, 31 Cedax, 31 Ceenu, 36 Cefaclor, 31 Cefadroxil, 31 Cefdinir, 31 Cefditoren Pivoxil, 31 Cefixime, 31 Cefpodoxime, 31 Cefprozil, 31 Ceftibuten Dihydrate, 31 Ceftin, 31 Cefuroxime, 31 Cefzil, 31 Celebrex, 8, 13 Celecoxib, 13 Celestone, 47 Celexa, 19 Cellcept, 37 Centrally Acting Adrenergic Agents, 24 Cephalexin, 31 Cephalosporins, 31 Certolizumab, 14 Cetirizine, 38, 39 Cetirizine/Pseudoephedrine, 39 Cevimeline, 44 Chantix, 60 Chemet, 58 Cheratussin DAC, 39 Chloral Hydrate, 21 Chlorambucil, 36
Chlordiazepoxide, 20, 29 Chlorhexidine Gluconate, 44 Chloroquine Phosphate, 33 Chlorothiazide, 25 Chlorpheniramine, 38, 39 Chlorpheniramine OTC, 38 Chlorpromazine, 20 Chlorpropamide, 45 Chlorthalidone, 26 Chlorzoxazone, 18 Cholecalciferol, 58 Cholestyramine/Aspartame, 26 Cholestyramine/Sucrose, 26 Choline Mag. Trisalicylate, 13 Cialis, 52 Ciclesonide, 44 Ciclopirox Cream, Gel, Suspension, 54 Ciclopirox Shampoo, 54 Cilostazol, 27 Ciloxan, 41 Ciloxan Ointment, 41 Cimetidine, 30 Cimzia, 14 Cinacalcet, 58 Cipro, 32, 43 Cipro HC, 43 Cipro XR, 32 Ciprodex, 43 Ciprofloxacin, 32, 41, 43 Ciprofloxacin/Dexamethasone, 43 Ciprofloxacin/Hydrocortisone, 43 Citalopram, 19 Citric Acid/K-Citrate, 51 Citric Acid/K-Citrate/Na-Citrate, 51 Citric Acid/Na-Citrate, 51 Claravis, 53 Clarinex Syrup, Tablets, 38 Clarinex-D 12 hour and 24-hour, 39 Clarithromycin, 30, 31 Claritin-D OTC, 39 Clemastine Fumarate, 38 Cleocin, 55 Climara, 48 Climara Pro, 48 Clindamycin, 32, 52, 55 Clindamycin HCl, 32 Clindamycin Lotion/Gel, 52 Clindamycin Solution, 52 Clindamycin/Benzoyl Peroxide, 52 Clinoril, 13 Clobetasol, 56 Clobetasol Topical Foam, 56 Clobetasol Topical Lotion, Shampoo, Spray, 56 Clobex, 56
65
Clocortolone Pivalate, 55 Cloderm, 55 Clomipramine, 19 Clonazepam, 17 Clonidine, 22, 24 Clonidine Extended-Release, 22, 24 Clonidine Transdermal, 24 Clopidogrel, 27 Clotrimazole, 33, 54 Clotrimazole Cream, Solution, 54 Clotrimazole Lotion, 54 Clozapine, 20 Clozaril, 20 CNS Stimulants, 21 Coagulants and Anticoagulants, 27 Coartem, 33 Codeine Phosphate, 15 Codeine Sulfate, 15 Codeine/Acetaminophen, 15 Codeine/Aspirin, 15 Cogentin, 17 Cognex, 16 Colazal, 30 Col-Benemid, 59 Colchicine, 59 Colchicine/Probenecid, 59 Colcrys, 59 Colesevelam, 26 Colestipol, 26 Collagenase, 53 Colony Stimulating Factors, 27 Coly-Mycin S Otic, 43 Colyte, 29 Combigan, 42 Combination Antihypertensive Agents, 24 Combination Diabetic Agents, 45 Combipatch, 48 Combivent, 40 Combivir, 35 Commit, 59 Compazine, 28 Complera, 35 Comtan, 18 Concerta, 22 Condylox, 53 Conjugated Estrogens, 48 Contraceptive Agents, Other, 50 Copaxone, 12, 38 Copegus, 34 Cordarone, 22 Cordran, 55 Cordran SP, 55 Coreg, 9, 23 Coreg CR, 9, 23
Corgard, 23 Cortef, 47 Cortenema, 30 Cortifoam, 30 Cortisone, 47 Cortisone Acetate, 47 Cortisporin, 41, 43 Cortisporin Ophthalmic, 41 Cortisporin-TC, 43 Cortomycin Ointment, 41 Cosopt, 42 Coumadin, 27 Covera HS, 24 COX-2 Inhibitor Agents, 13 Cozaar, 23 Creon, 30 Crestor, 26 Crixivan, 35 Crolom, 43 Cromolyn Ophthalmic Solution, 43 Cromolyn Oral Solution, 44 Cromolyn Sodium, 44 Crotamiton, 57 Cuprimine, 13, 58 Cutivate Cream, Ointment, 55 Cutivate Lotion, 55 Cuvposa Solution, 29 Cyanocobalamin, 58 Cyclessa, 50 Cyclobenzaprine, 18 Cyclocort, 56 Cyclogyl, 42 Cyclopentolate, 42 Cyclophosphamide, 35 Cyclosporine, 37, 43 Cyclosporine Ophthalmic Emulsion, 43 Cymbalta, 9, 20 Cyproheptadine, 38 Cytadren, 47 Cytomel, 46 Cytotec, 29 Cytovene, 34 Cytoxan, 35
D D.H.E. 45, 14 Dabigatran, 27 Dacogen, 12, 37 Dalfampridine, 38 Dalmane, 20 Dalteparin, 27 Danazol, 47 Danocrine, 47
66
Dantrium, 18 Dantrolene Sodium, 18 Dapsone, 35, 53 Dapsone Gel, 53 Daraprim, 33 Darbepoetin, 27 Darifenacin, 51 Darunavir, 34 Dasatinib, 36 Daypro, 13 Daytrana, 22 DDVAP, 51 Decadron, 41, 47 Decitabine, 37 Deconamine SR, 39 Delatestryl, 47 Delavirdine, 34 Demadex, 25 Demecarium, 42 Demerol, 15 Denavir Cream, 56 Denosumab, 48 Depakene, 17 Depakote, 14, 17 Depakote ER, 14 Depen, 58 Depo-Provera, 50 Depo-Subq Provera, 50 Depo-Testosterone, 47 Derma-Smoothe/FS, 55 DermOtic, 44 Desipramine, 19 Desirudin, 27 Desloratadine, 38, 39 Desloratadine/Pseudoephedrine, 39 Desmopressin, 51 Desogen, 49 Desogestrel/Ethinyl Estradiol, 49, 50 Desonide, 55 Desowen, 55 Desoximetasone 0.05% Cream, 55 Desoximetasone 0.05% Gel, 55 Desoximetasone 0.25%, 56 Desvenlafaxine, 19 Desyrel, 19 Detrol, 52 Detrol LA, 52 Dexamethasone, 41, 42, 47 Dexamethasone 0.05% Ointment, 41 Dexamethasone 0.1% Solution, 41 Dexasol, 41 Dexchlorpheniramine, 38 Dexedrine, 21 Dexmethylphenidate, 21, 22
DexPak, 47 Dextroamphetamine, 21, 22 Diabeta, 45 Diabetic Agents, 45 Diabetic Supplies, 46 Diabinese, 45 Diamox, 40 Diamox Sequels, 40 Diaphragms, 50 Diastat, 17 Diastat AcuDial, 17 Diazepam, 17, 18, 20 Dibenzyline, 25 Diclofenac 1% Gel, 56 Diclofenac 1.3% Patch, 56 Diclofenac 3% Gel, 53 Diclofenac Potassium, 13 Diclofenac Sodium, 13, 41 Dicloxacillin, 32 Dicyclomine, 29 Didanosine (ddI), 34, 35 Didronel, 47 Differin 0.1% Cream/Gel, 52 Differin 0.3% Gel, 53 Diflorasone Diacetate, 56 Diflucan, 33 Diflunisal, 13 Difluprednate, 42 Digestive Enzymes, 30 Digoxin, 27 Dihydrocodeine/APAP/Caffeine, 15 Dihydroergotamine, 14, 15 Dihydrotachysterol, 58 Dilacor XR, 24 Dilantin 100mg Capsule & Oral Suspension, 17 Dilantin 30mg Capsules & 50mg Chew Tabs, 17 Dilatrate SR, 28 Dilaudid, 15 Diltia XT, 24 Diltiazem, 24 Diltiazem CD, 24 Diltiazem LA, 24 Diltiazem SA Capsules, 24 Diltiazem SR, 24 Diovan, 8, 23, 25 Diovan HCT, 8, 25 Dipentum, 31 Diphenhydramine, 38 Diphenoxylate/Atropine, 28 Dipivefrin, 42 Diprolene AF, 56 Diprolene Gel, Ointment, 56 Diprolene Lotion, 56 Diprosone, 55
67
Dipyridamole, 27 Direct Renin Inhibitor, 23 Direct Vasodilator Agents, 26 Disalcid, 13 Disease Modifying Antirheumatic Agents (DMARDs), 13 Disopyramide, 22 Disopyramide CR, 22 Disulfiram, 59 Ditropan, 51 Ditropan XL, 51 Diuril, 25 Divalproex ER, 14 Divalproex Sodium, 17 Docetaxel, 37 Dofetilide, 22 Dolasetron, 28 Dolobid, 13 Domeboro, 43 Donepezil, 16 Donnatal, 29 Donnatal Extentabs, 29 Dornase Alpha, 40 Dorzolamide, 42 Dorzolamide/Timolol, 42 Dostinex, 17 Dovonex Cream, 53 Dovonex Ointment, 53 Dovonex Solution, 53 Doxazosin, 26, 52 Doxazosin XL, 52 Doxepin, 19, 53 Doxepin Cream, 53 Doxercalciferol, 58 Doxycycline, 33, 35 Doxycycline Hyclate, 35 Drisdol, 58 Drithocreme HP 1%, 53 Dritho-Scalp 0.5%, 53 Dronabinol, 28 Dronedarone, 22 Drosperinone/Ethinyl Estradiol, 49 Droxia, 36 Drugs for Pheochromocytoma, 25 Drysol, 53 Duetact, 45 Dulera, 40 Duloxetine, 20 DuoNeb, 40 Duragesic, 15 Durezol, 42 Duricef, 31 Dutasteride, 52 Dutasteride/Tamsulosin, 52 Dyazide, 25
Dynacin, 33 Dynacirc, 24 Dynacirc CR, 24 Dysport, 18
E Echothiophate Iodide, 42 Econazole, 54 EDEX, 52 Edluar, 21 Edurant, 35 EES, 32 Efavirenz, 35 Effexor, 19 Effexor XR, 19 Effient, 27 Eflone, 41 Efudex, 53 Elavil, 19 Eldepryl, 18 Electrolyte Agents, 57 Elestat, 43 Eletriptan, 15 Elidel, 53 Eligard, 37 Elimite, 57 Ella, 50 Elmiron, 51 Elocon, 55 Eltrombopag, 27 Emadine, 43 Emcyt, 36 Emedastine, 43 Emend, 28, 29 Emend Injection, 29 Emergency Kits, 59 EMLA, 56 Empirin #2, #3, #4, 15 EMSAM, 20 Emtricitabine, 35 Emtricitabine/Tenofovir, 35 Emtricitabine/Tenofovir/Efavir, 35 Emtriva, 35 Enablex, 51 Enalapril, 23, 24 Enalapril/HCTZ, 24 Enbrel, 14 Enfuvirtide, 35 Enoxaparin, 27 Entacapone, 18 Entecavir, 34 Entex LA, 40 Entocort EC, 30
68
Enulose, 30 Epinastine, 43 Epinephrine 0.15mg/0.3ml, 59 Epinephrine 0.3mg/0.3ml, 59 Epinephrine Syringe, 59 EpiPen, 59 EpiPen Jr, 59 Epivir, 34, 35 Epivir HBV, 34 Eplerenone, 25 Epoetin Alpha, 27 Epogen, 12, 27 Epoprostenol, 25 Epzicom, 34 Ergocalciferol, 58 Ergomar, 15 Ergotamine Tartrate, 15 Ergotamine/Caffeine, 14 Eribulin, 37 Erlotinib, 36 EryPed Suspension, 32 Ery-Tab, 31 Erythrocin, 32 Erythromycin, 31, 32, 41, 52 Erythromycin Base, 31, 32, 41 Erythromycin Base IR Tablet, 31 Erythromycin Ethylsuccinate, 32 Erythromycin Stearate, 32 Erythromycin Topical, 52 Erythromycin/Benzoyl Peroxide, 52 Erythromycin/Sulfisoxazole, 32 Escitalopram Oxalate, 19 Esgic Plus, 14 Eskalith, 20 Esomeprazole, 29 Esterified Estrogens/Methyltestosterone, 48 Estrace, 48 Estraderm, 48 Estradiol, 48, 50 Estradiol, Transdermal, 48 Estradiol, Vaginal Ring, 48 Estradiol/Levonorgestrel Patch, 48 Estradiol/Norethindrone, 48 Estramustine, 36 Estratest, 48 Estratest H.S., 48 Estring, 48 Estrogen Agents, 48 Estrogen/Medroxyprogesterone, 48 Estrogens, Esterified, 48 Estropipate, 48 Estrostep Fe, 50 Eszopiclone, 21 Etanercept, 14
Ethambutol, 33 Ethmozine, 22 Ethosuximide, 17 Ethynodiol/Ethinyl Estradiol, 49 Etidronate, 47 Etodolac, 13 Etodolac XL, 13 Etonogestrel/Ethinyl Estradiol Vaginal Ring, 50 Etoposide, 36 Etravirine, 35 Euflexxa, 12, 14 Eulexin, 36 Eurax Lotion, 57 Everolimus, 36 Evista, 48 Evoxac, 44 Exalgo, 16 Exelderm, 55 Exelon, 16 Exelon Patch, 16 Exemestane, 36 Exenatide, 46 Exforge, 25 Exforge HCT, 25 Expectorant Agents, 40 Extavia, 12, 38 Ezetimibe, 26 Ezetimibe/Simvastatin, 26
F Factive, 32 Famciclovir, 34 Famotidine, 30 Famvir, 34 Fanapt, 20 Fansidar, 33 Fareston, 36 Febuxostat, 59 Feldene, 13 Felodipine, 24 Femara, 36 Femcon Fe, 50 Femhrt, 48 Femring, 48 Fenofibrate, 26 Fenoglide, 26 Fenoprofen, 13 Fentanyl, 15, 16 Fentora Buccal Tablet, 16 Fesoterodine, 51 Fexofenadine, 38, 39 Fexofenadine Suspension, 38 Fexofenadine/Pseudoephedrine, 39
69
Fibromyalgia Agents, 21 Filgrastim, 27 Finacea 15% Gel, 53 Finasteride, 52 Fingolimod, 38 Fioricet, 14, 15 Fioricet/Codeine, 15 Fiorinal, 14, 15 Fiorinal/Codeine, 15 First-Testosterone Cream & Ointment, 47 Flagyl, 31, 32 Flagyl ER, 31, 32 Flarex, 42 Flavoxate, 51 Flecainide, 22 Flector, 56 Flexeril, 18 Flolan, 25 Flomax, 52 Flonase, 44 Florinef, 47 Flovent Diskus, 44 Flovent HFA, 44 Floxin, 32, 43 Floxin Otic, 43 Fluconazole, 33 Fludarabine, 36 Fludrocortisone Acetate, 47 Flumadine, 34 Flumist, 59 Flunisolide, 44 Fluocinolone, 44, 55 Fluocinolone 0.01% Oil, 55 Fluocinolone Shampoo, 55 Fluocinonide 0.05%, 56 Fluocinonide 0.1%, 56 Fluocinonide/Emollient, 56 Fluoride Agents, 58 Fluorometholone, 41, 42 Fluorometholone 0.1% Suspension, 42 Fluorouracil, 53 Fluoxetine, 19 Fluoxymesterone, 47 Fluphenazine, 20 Flurandrenolide, 55 Flurazepam, 20 Flurbiprofen, 13, 41 Flurbiprofen Sodium, 41 Flutamide, 36 Fluticasone Cream, Ointment, 55 Fluticasone Furoate, 44 Fluticasone Inhaler, 44 Fluticasone Lotion, 55 Fluticasone Powder, 44
Fluticasone Propionate, 44 Fluticasone/Salmeterol, 40 Fluvastatin, 26 Fluvastatin XL, 26 Fluvoxamine, 19 FML, 41, 42, 43 FML Forte, 42 FML SOP Ointment, 42 FML-S, 43 Focalin, 21, 22 Focalin XR, 22 Folic Acid, 58, 59 Folic Acid/Multivitamins with Minerals, 58 Fondaparinux, 27 Foradil, 40 Formoterol, 40 Forteo, 48 Fortesta, 47 Fortovase, 35 Fosamax, 47 Fosamax-D, 47 Fosamprenavir, 35 Fosaprepitant, 29 Fosfomycin Tromethamine, 32 Fosinopril, 23, 24 Fosinopril/HCTZ, 24 Fosrenol, 57 Fragmin, 27 Freestyle, 46 Frova, 9, 15 Frovatriptan, 15 Furadantin, 51 Furazolidone, 31 Furosemide, 25 Furoxone, 31 Fusilev, 12, 37 Fuzeon, 12, 35
G Gabapentin, 17 Gabarone, 17 Gabitril, 17 Galantamine, 16 Gallstone Solubilizing Agents, 30 Ganciclovir, 34 Gantrisin, 33 Garamycin, 41, 54 Gastrocrom, 44 Gastrointestinal Stimulant Agents, 30 Gatifloxacin 0.3%, 32, 41 Gatifloxacin 0.5%, 41 Gefitinib, 36 Gelnique, 52
70
Gemfibrozil, 26 Gemifloxacin, 32 Generess Fe, 50 Genitourinary Smooth Muscle Relaxant Agents, 51 Genotropin, 49 Gentamicin, 41, 54 Gentamicin Sulfate, 54 Gentamicin/Prednisolone, 41 Geodon, 21 Gilenya, 38 Glatiramer, 38 Gleevec, 12, 36 Glimepiride, 45 Glipizide, 45 Glipizide ER, 45 Glipizide/Metformin, 45 Glucagon, 45 Glucophage, 45 Glucophage XR, 45 Glucotrol, 45 Glucotrol XL, 45 Glucovance, 45 Glyburide, 45 Glyburide/Metformin, 45 Glycopyrrolate, 29 Glyset, 45 Golimumab, 14 Golytely, 29 Goserelin Acetate, 37 Gout Agents, 59 Granisetron, 28 Granul-Derm, 53 Grifulvin V, 33 Griseofulvin Microsize, 33 Griseofulvin Ultramicrosize, 33 Gris-Peg, 33 Growth Hormone Receptor Antagonist, 49 Guaifed-PD, 39 Guaifen PSE, 39 Guaifenesin, 39, 40 Guaifenesin w/ Codeine, 39 Guaifenesin/Codeine, 39 Guaifenesin/Dextromethorphan, 39 Guaifenesin/Hydrocodone, 39 Guaifenesin/Phenylephrine, 40 Guaifenesin/Pseudoephedrine, 39 Guanfacine, 22, 24 Guanfacine Extended-Release, 22 Gynazole-1, 55
H H2 Antagonist Agents, 30 Halaven, 12, 37
Haldol, 20 Haldol Decanoate 50mg ampule, 20 Haldol Decanoate 50mg vial & 100mg vial & ampule, 20 HalfLytely, 29 Halobetasol, 56 Haloperidol, 20 Haloperidol Decanoate Injection, 20 Haloperidol Lactate Injection, 20 Halotestin, 47 HC Pramosone, 54 Heavy Metal Antagonist Agents, 58 Hectorol, 58 Helidac, 30 Hematological Agents, 27 Hemorheologic Agents, 27 Heparin, 27 Heparin Sodium, 27 Hepatitis C Agents, 34 Hepsera, 34 Herceptin, 12, 37 Hexachlorophene, 53 Hexalen, 36 Histinex HC, 39 HIV Antiviral Agents, 34 Hivid, 35 Hizentra, 38 Homatropine 5% Solution, 42 Humalog, 46 Humalog Mix, 46 Human Growth Hormones, 48 Humatin, 31 Humatrope, 49 Humira, 14 Humorsol, 42 Humulin, 45 Hyalgan, 12, 14 Hyaluronan, 13 Hycamtin, 12, 36, 37 Hycamtin Injection, 37 Hydralazine, 26 Hydrea, 36 Hydrochlorothiazide (HCTZ), 26 Hydrocodone/Acetaminophen, 15 Hydrocodone/Chlorpheniramine, 39 Hydrocodone/Homatropine, 39 Hydrocodone/Ibuprofen, 15 Hydrocortisone, 30, 41, 43, 47, 54, 55, 56 Hydrocortisone Acetate, 30, 54 Hydrocortisone Acetate 2.5%, 54 Hydrocortisone Butyrate, 55, 56 Hydrocortisone Enema, 30 Hydrocortisone Oral, 47 Hydrocortisone Valerate, 55 Hydrodiuril, 26
71
Hydromorphone, 15, 16 Hydromorphone, Extended-release, 16 Hydroxychloroquine, 13, 33 Hydroxyurea, 36 Hydroxyzine, 21, 38 Hydroxyzine Pamoate, 21, 38 Hygroton, 26 Hylan G-F 20, 14 Hyoscyamine Sulfate, 29 Hytakerol, 58 Hytone, 55 Hytrin, 26, 52 Hyzaar, 24
I Ibandronate, 47 Ibuprofen, 13 Iloperidone, 20 Iloprost, 25 Ilotycin, 41 Imatinib Mesylate, 36 Imdur, 28 Imipramine HCl, 19 Imiquimod, 53 Imitrex, 14 Imitrex Injection, 14 Imitrex Nasal Spray, 14 Immune Globulin Agents, 38 Immune Globulin, Subcutaneous, 38 Immunization, 9, 59 Immunomodulator Injectable Agents, 37 Immunosuppressant Agents, 35, 37 Imodium, 28 Impotency Agents, 52 Imuran, 13, 37 Incivek, 34 IncobotulinumtoxinA, 18 Indapamide, 26 Inderal, 23 Inderal LA, 23 Indinavir, 35 Indocin, 13 Indocin SR, 13 Indomethacin, 13 Indomethacin SR, 13 Infergen, 38 Inflamase Mild, 42 Infliximab, 14 Influenza Vaccine 2011-2012, 59 Influenza Virus Vaccine, 59 Inhaled Adrenal Corticosteroid Agents, 43 Inhaled Anticholinergic Agents, 39 Inhaled Anti-inflammatory Agents, 43
Inhaled Sympathomimetic (Adrenergic) Agents, 40 Innohep, 27 Inspra, 25 Insulin Agents, 45 Insulin Aspart, 45 Insulin Aspart Protamine/Aspart, 45 Insulin Detemir, 46 Insulin Glargine Human, 46 Insulin Glulisine, 46 Insulin Lispro, 46 Insulin Lispro Protamine/Lispro, 46 Insulin Syringes, Needles and Pen Needles, 46 Insulin, Human, 45 Intal Inhaler, 44 Intal Solution for Inhalation, 44 Intelence, 35 Interferon Alfa 2b, 38 Interferon Alfacon-1, 38 Interferon Beta-1a, 38 Interferon Beta-1b, 38 Intron A, 12, 38 Intuniv, 9, 22 Invega, 21 Invega Sustenna, 21 Invirase, 34 Iodoquinol (Diiodohydroxyquin), 31 Ipilimumab, 37 Ipratropium, 39, 40 Iprivask, 27 Iquix, 41 Irbesartan, 23, 25 Irbesartan/HCTZ, 25 Iressa, 36 Isentress, 35 Isoniazid, 33 Isopto Atropine, 42 Isopto Carbachol, 42 Isopto Homatropine, 42 Isopto Hyoscine, 42 Isordil, 27 Isosorbide Dinitrate, 27, 28 Isosorbide Dinitrate SR, 28 Isosorbide Mononitrate, 28 Isotretinoin, 53 Isradipine, 24 Isradipine CR, 24 Istodax, 12, 37 Itraconazole, 33 Ivermectin, 31 Ixabepilone, 37 Ixempra, 12, 37
72
J Jalyn, 52 Janumet, 9, 45 Januvia, 9, 45 Jevtana, 12, 37 Junel, 49
K Kadian, 16 Kaletra, 35 Kaon-Cl 10, 57 Kapvay, 22 Kayexalate, 57 KCl, 57 K-Dur, 57 Keflex, 31 Kemadrin, 18 Kenalog, 40, 55, 56 Kenalog Aerosol Spray, 56 Kenalog In Orabase, 40 Keppra, 17 Keppra XR, 17 Kerlone, 23 Ketek, 31 Ketoconazole, 33, 54 Ketolides, 31 Ketoprofen, 13 Ketorolac, 13, 41, 42 Ketorolac 0.4%, 41 Ketorolac 0.5%, 41, 42 Ketotifen, 43 Klaron, 56 Klonopin, 17 K-Lor, 57 Klor-Con 8, 57 K-Lyte, 57 K-Lyte CL DS, 57 K-Phos M.F., 57 K-Phos Neutral, 57 K-Phos No. 2, 57 K-Phos Original, 57 Kristalose Packets, 30 K-Tabs, 57 Kwell, 57 Kytril Oral Solution, 28 Kytril Tablet, 28
L Labetalol, 23 Lac-Hydrin, 53 Lacosamide, 17
Lactulose, 30 Lamictal 200mg, 17 Lamictal 25mg, 17 Lamictal 5mg and 25mg, 17 Lamictal XR, 17 Lamisil, 33, 55 Lamisil Granules, 33 Lamisil Spray, 55 Lamivudine, 34, 35 Lamivudine (3TC), 35 Lamotrigine, 17 Lamotrigine Chewable Tablets, 17 Lamotrigine, Extended Release, 17 Lanoxin, 27 Lanreotide, 49 Lansoprazole, 29, 30 Lanthanum, 57 Lantus, 46 Lapatinib, 36 Lariam, 33 Lasix, 25 Latanoprost, 43 Latuda, 20 Laxative Agents, 30 Leflunomide, 13 Lenalidomide, 36 Leprostatic Agents, 35 Lescol, 26 Lescol XL, 26 Letairis, 25 Letrozole, 36 Leucovorin, 37 Leukeran, 36 Leukine, 12, 27 Leukotriene Receptor Antagonists, 44 Leuprolide Acetate, 36, 37 Levalbuterol, 40 Levalbuterol HFA, 40 Levaquin, 32 Levbid, 29 Levemir, 46 Levetiracetam, 17 Levetiracetam ER, 17 Levitra, 52 Levlite, 49 Levobunolol, 42 Levocetirizine, 39 Levofloxacin, 32, 41 Levoleucovorin, 37 Levonorgestrel, 49, 50 Levonorgestrel/Ethinyl Estradiol, 49, 50 Levora, 49 Levothyroxine, 46 Levoxyl, 46
73
Levsin, 29 Lexapro, 19 Lexiva, 35 Lialda, 9, 31 Librium, 20 Lidex, 56 Lidex E, 56 Lidocaine, 40, 56 Lidocaine 2% Gel, 56 Lidocaine 3% Cream, Lotion, 56 Lidocaine 4% Injection, 56 Lidocaine 5% Ointment, 56 Lidocaine Medicated Patch, 56 Lidocaine Viscous, 56 Lidocaine, Viscous, 40 Lidocaine/Prilocaine, 56 Lidoderm, 56 Lindane, 57 Linezolid, 32 Liothyronine, 46 Liotrix, 46 Lipitor 10mg & 20mg, 26 Lipitor 40mg & 80mg, 26 Lipofen, 26 LiQuadd, 22 Liraglutide, 46 Lisdexamfetamine, 22 Lisinopril, 23, 24 Lisinopril/HCTZ, 24 Lithium Carbonate (all forms), 20 Lithobid, 20 Livalo, 26 Local Anesthetic Agents, 40 Locoid, 55, 56 Locoid Lipocream, 56 Lodine, 13 Lodine XL, 13 Lodosyn, 18 Lodoxamide, 43 Loestrin, 49, 50 Loestrin Fe, 50 Lofibra, 26 Lomotil, 28 Lomustine, 36 Loop Diuretics, 25 Loperamide, 28 Lopid, 26 Lopinavir/Ritonavir, 35 Lopressor, 23 Loprox Cream, Gel, Suspension, 54 Loprox Shampoo, 54 Loratadine, 38, 39 Loratadine OTC, 38 Loratadine/Pseudoephedrine, 39
Lorazepam, 20 Losartan, 23, 24 Losartan/HCTZ, 24 Lotemax, 42 Lotensin, 23, 24 Lotensin HCT, 24 Loteprednol 0.2%, 42 Loteprednol 0.5%, 42 Lotrel, 24 Lotrimin Cream, Solution, 54 Lotrimin Lotion, 54 Lotrisone Cream, 54 Lotrisone Lotion, 54 Lotronex, 28 Lovastatin, 26 Lovastatin/Niacin, 26 Lovenox, 27 Low-Ogestrel, 50 Loxapine, 20 Loxitane, 20 Lozol, 26 Lubiprostone, 30 Ludiomil, 19 Lumigan, 43 Lunesta, 21 Lupron, 12, 36, 37 Lupron Depot, 12, 37 Lurasidone, 20 Luride, 58 Luvox, 19 Luvox CR, 19 Luxiq, 55 Lyrica, 17 Lysodren, 36 Lysteda, 27
M M.A.O. Inhibitor Agents, 19 Macrobid, 51 Macrodantin, 51 Macrolide Antibiotic Agents, 31 Malarone, 33 Malathion, 57 Mandelamine, 51 Maprotiline, 19 Maraviroc, 35 Marinol, 28 Mast Cell Stabilizer, 44 Matulane, 36 Mavik, 23 Maxair Autohaler, 40 Maxalt/Maxalt MLT, 15 Maxidex, 42
74
Maxiflor, 56 Maxitrol, 41 Maxivate, 55 Maxzide, 25 Mebaral, 17 Mebendazole, 31 Meclizine, 28 Meclofenamate, 13 Meclomen, 13 Medrol, 47 Medrol Dosepak, 47 Medroxyprogesterone, 50, 51 Mefenamic Acid, 13 Mefloquine, 33 Megace, 36 Megestrol, 36 Mellaril, 20 Meloxicam, 13 Melphalan, 36 Memantine, 16 Menest, 48 Meperidine, 15 Mephobarbital, 17 Mephyton, 58 Mepron, 33 Mercaptopurine, 36 Mesalamine CR Capsules, 30 Mesalamine DR Tablets, 30, 31 Mesalamine Enema, 30 Mesalamine ER Capsule, 31 Mesalamine Suppositories, 31 Mesna, 36 Mesnex, 36 Mestinon, 19 Mestinon Timespan, 19 Metadate CD, 22 Metaglip, 45 Metaproterenol, 40 Metaproterenol Oral, 40 Metaxalone, 18 Metformin, 45 Meth/Me Blue/BA/Salicy/ATP/Hyos, 51 Meth/Sod Phos/Meth Blue/Hyos, 51 Methadone, 15 Methadone HCl, 15 Methazolamide, 40 Methenamine Mandelate, 51 Methergine, 51 Methimazole, 46 Methitest, 47 Methocarbamol, 18 Methotrexate, 13, 36 Methoxsalen, 53 Methyldopa, 24
Methylergonovine Maleate, 51 Methylnaltrexone, 16 Methylphenidate, 21, 22 Methylphenidate ER, 22 Methylphenidate, Transdermal, 22 Methylprednisolone, 47 Methyltestosterone, 47 Metipranolol, 42 Metoclopramide, 28, 30 Metolazone, 26 Metoprolol Succinate, 23 Metoprolol Tartrate, 23 Metrogel-Vaginal, 55 Metronidazole, 30, 31, 32, 54, 55 Metronidazole Cream, Gel, 54 Metronidazole, Extended Release, 31 Mevacor, 26 Mexiletine, 22 Mexitil, 22 Miacalcin Injection, 48 Miacalcin Nasal Spray, 48 Miconazole, 54, 55 Miconazole (OTC), 54 Miconazole Nitrate (OTC), 54 Micro-K, 57 Micro-K 10, 57 Micronase, 45 Midamor, 25 Midodrine, 40 Midrin, 14 Miglitol, 45 Migraine Agents, 14 Migranal, 14, 15 Migranal Nasal, 15 Milnacipran, 21 Minipress, 26 Minocin, 33 Minocycline, 33 Minoxidil tablet, 26 Mintezol, 31 Miralax, 30 Mirapex, 18 Mirapex ER, 18 Mircette, 50 Mirtazapine, 19 Miscellaneous Agents for Osteoporosis, 48 Miscellaneous Analgesics, 16 Miscellaneous Antibiotic Agents, 32 Miscellaneous Antidepressant Agents, 19 Miscellaneous Anxiolytics, Sedatives and Hypnotics, 21 Miscellaneous EENT Agents, 44 Miscellaneous Injectable Agents, 38 Miscellaneous Injectable Diabetic Agents, 46 Miscellaneous Opiate Agents, 16
75
Miscellaneous Respiratory Aids, 44 Miscellaneous Skin/Mucous Membrane Agents, 53 Miscellaneous Vitamins, 58 Misoprostol, 29 Mitotane, 36 Mobic, 13 Modafinil, 22 Modicon, 49 Moduretic, 25 Moexipril, 23, 24 Moexipril/HCTZ, 24 Mometasone, 40, 44, 55 Mometasone Furoate, 55 Mometasone/Formoterol, 40 Monistat 3, 55 Monoket, 28 Monophasic Oral Contraceptives, 49 Monopril, 23, 24 Monopril-HCT, 24 Montelukast, 44 Monurol, 32 Moricizine, 22 Morphine, 15, 16 Morphine SR, 15, 16 Motrin, 13 MoviPrep, 29 Moxifloxacin, 32, 41 Moxifloxacin HCl, 32 MS Contin, 15 MSIR, 15 Mucolytic Agents, 40 Mucomyst, 40 Multaq, 22 Multiple Sclerosis Agents, 38 Multivitamin Agents, 59 Mupirocin Cream, 54 Mupirocin Nasal Ointment, Preservative Free, 54 Mupirocin Ointment, 54 Muscle Relaxant Agents, 18 MUSE, 52 Myambutol, 33 Mycelex Troche, 33 Mycobutin, 34 Mycolog II, 54 Mycophenolate, 37 Mycophenolate DR, 37 Mycostatin, 33 Mydriacyl, 42 Myfortic, 37 Myleran, 36 Myobloc, 18 Mysoline, 17
N Nabumetone, 13 Nadolol, 23 Naftifine, 54 Naftin, 54 Nalfon, 13 Naltrexone, 16 Namenda, 16 Naprosyn, 13 Naproxen, 13 Naproxen Sodium, 13 Naratriptan, 14 Narcotic Antitussive Agents, 39 Nardil, 19 Nasacort AQ, 44 Nasal Antihistamine, 39 Nasal Inhaled Corticosteroid Agents, 44 Nasarel, 44 Nasonex, 44 Natalizumab, 38 Nateglinide, 45 Nature-Throid, 46 Navane, 20 Nebivolol, 23 Nebupent, 34 Necon, 50 Nedocromil, 43 Nefazodone, 19 Nelfinavir, 35 Neomycin, 31, 41, 43 Neomycin Sulfate, 31 Neoral, 10, 37 Neosporin Ophth. Ointment, 41 Neosporin Ophth. Solution, 41 Nepafenac, 42 Nephrocaps, 58, 59 Nephrocaps QT, 59 Neptazane, 40 Neulasta, 12, 27 Neupogen, 12, 27 Neuromuscular Blocking Agents, 18 Neurontin, 17 Neurontin Oral Solution, 17 Nevanac, 42 Nevirapine, 35 Nexavar, 12, 36 Nexiclon XR, 24 Nexium, 29 Niacin, 26, 58 Niacin ER, 26 Niaspan, 26 Nicardipine, 24 Nicoderm CQ, 60
76
Nicotine Gum, 60 Nicotine, Inhaler, 60 Nicotine, Nasal Spray, 60 Nicotine, Polacrilex, 59, 60 Nicotine, Transdermal, 60 Nicotrol, 60 Nicotrol NS, 60 Nifedipine, 24 Nifedipine SR (all forms), 24 Nilandron, 36 Nilotinib, 36 Nilutamide, 36 Nimodipine, 24 Nimotop, 24 Nisoldipine ER, 24 Nitazoxanide, 33 Nitrate Agents, 27 Nitrek, 28 Nitrobid, 28 Nitro-Dur, 28 Nitrofurantoin Macrocrystals, 51 Nitrofurantoin Oral Suspension, 51 Nitroglycerin Ointment, 28 Nitroglycerin Patches, 28 Nitroglycerin Spray, 28 Nitroglycerin Sublingual, 28 Nitrolingual Spray, 28 Nitroquick, 28 Nitrostat SL, 28 Nizatidine, 30 Nizoral, 33, 54 Noctec, 21 Nolvadex, 36 Nonsedating Antihistamine Agents, 38 Nonsteroidal Anti-inflammatory Agents, 13 Non-Stimulant ADHD Agents, 22 Nonsulfonylureas, 45 Nor QD, 50 Nora-BE, 50 Norditropin, 12, 49 Norethindrone, 49, 50, 51 Norethindrone Acetate, 51 Norethindrone/Ethinyl Estradiol, 49, 50 Norethindrone/Ethinyl Estradiol/Fe, 50 Norethindrone/Mestranol, 50 Norflex, 18 Norfloxacin, 32 Norgesic, 18 Norgestimate/Ethinyl Estradiol, 50 Norgestrel/Ethinyl Estradiol, 50 Norinyl 1/35, 49 Norinyl 1/50, 50 Normodyne, 23 Noroxin, 32
Norpace, 22 Norpace CR, 22 Norpramin, 19 Nortrel, 50 Nortriptyline, 19 Norvasc, 23 Norvir, 35 Novolin, 45 NovoLog, 45 NovoLog Mix, 45 Nplate, 27 Nulev, 29 Nutropin, 12, 49 Nutropin AQ, 12, 49 Nuvaring, 50 Nuvigil, 22 Nystatin, 33, 54
O Octreotide IR, 49 Octreotide LAR Depot, 49 Ocufen, 41 Ocuflox, 41 Ocupress, 42 Ofatumumab, 37 Ofloxacin, 32, 41, 43 Oforta, 12, 36 Ogen, 48 Ogestrel, 50 Olanzapine, 20, 21 Olanzapine/Fluoxetine, 20 Oleptro, 9, 20 Olmesartan, 23, 25 Olmesartan/HCTZ, 25 Olopatadine 0.1%, 43 Olopatadine 0.2%, 43 Olsalazine, 31 Olux, 56 Omalizumab, 44 Omeprazole, 29 Omeprazole Magnesium, 29 Omnaris, 44 Omnicef, 31 Omnipred, 41 OnabotulinumtoxinA, 18 Ondansetron HCl, 28 One Touch, 46 Onsolis Buccal Film, 16 Opana, 15, 16 Opana ER, 16 Ophthalmic Antibiotic Agents, 41 Ophthalmic Antiviral Agents, 42 Ophthalmic Beta Blockers, 42
77
Ophthalmic Miotic Agents, 42 Ophthalmic Miscellaneous Agents, 43 Ophthalmic Mydriatic Agents, 42 Ophthalmic Prostaglandin Agonists, 43 Ophthalmic Sulfonamide Agents, 43 Opiate Agonists, 15, 16 Opiate Agonists/Antagonists, 16 Opiate Antagonists, 16 Opium, 28 Opium Tincture, 28 Optipranolol, 42 Optivar, 43 Oral Adrenocorticosteroid Agents, 47 Oral Bowel Evacuant Combination, 29 Oral Bowel Evacuant Solution, 29 Oral Bowel Evacuation Tablets, 29 Oral Contraceptive Agents, 49 Oral Sympathomimetic (Adrenergic) Agents, 40 Orapred ODT, 47 Orasone, 47 Oraxyl, 35 Orencia, 37 Orinase, 45 Orphenadrine Citrate, 18 Orphenadrine/Aspirin/Caffeine, 18 Orphengesic Forte, 18 Ortho All Flex, 50 Ortho Cyclen, 50 Ortho Evra, 50 Ortho Micronor, 50 Ortho Novum 1/35, 49 Ortho Novum 1/50, 49 Ortho Novum 10/11, 50 Ortho Novum 7/7/7, 50 Ortho Tri-Cyclen, 50 Ortho-Cept, 49 Ortho-Est, 48 Orthovisc, 12, 13 Oruvail, 13 Oseltamivir, 34 OsmoPrep, 29 Oticaine, 40 Ovcon-35, 49 Ovide, 57 Oxandrin, 47 Oxandrolone, 47 Oxaprozin, 13 Oxazepam, 20 Oxcarbazepine, 17 Oxsoralen, 53 Oxybutynin, 51, 52 Oxybutynin ER, 51 Oxybutynin Gel, 52 Oxybutynin Transdermal Patch, 52
Oxycodone, 15, 16 Oxycodone/Acetaminophen, 15 Oxycodone/Aspirin, 15 OxyContin, 16 Oxyfast, 15 Oxyir, 15 Oxymetholone, 47 Oxymorphone, 15, 16 Oxymorphone, Extended-release, 16 Oxytocic Agents, 51 Oxytrol, 52
P Pacerone, 22 Paclitaxel, 36 Paliperidone, 21 Palivizumab, 35 Palonosetron, 28 Pamelor, 19 Pamidronate Disodium, 47 Pancreaze, 30 Pancrelipase, 30 Panitumumab, 37 Panlor DC, 15 Pantoprazole, 29 Parafon DSC, 18 Parasympathomimetic (Cholinergic) Agents, 19 Parcopa, 18 Paregoric, 28 Parepectolin, 28 Parlodel, 17 Parnate, 19 Paromomycin, 31 Paroxetine, 19 Pataday, 43 Patanol, 43 Paxil, 19 Paxil CR, 19 Paxil Suspension, 19 Pazopanib, 36 PCE, 32 Peak Flow Meters, 44 Pediapred, 47 Pediazole, 32 Peg-Filgrastim, 27 Peginterferon Alfa-2b, 34, 36 Peg-Intron, 12, 34 Pegvisomant, 49 Pemirolast, 43 Pen VK, 32 Pencyclovir, 56 Penicillamine, 13, 58 Penicillin G Benzathine, 32
78
Penicillin VK, 32 Penicillins, 32 Pentamidine, Aerosolized, 34 Pentasa, 30 Pentosan, 51 Pentoxifylline, 27 Pepcid, 30 Percocet, 15 Percodan, 15 Perforomist, 40 Periactin, 38 Peridex, 44 Perindopril, 23 Periodontal Collagenase Inhibitors, 35 Periostat, 35 Peripherally Acting Adrenergic Agents, 23 Permethrin, 57 Perphenazine, 20 Persantine, 27 Phenazopyridine, 51 Phenelzine, 19 Phenergan, 21, 28, 38, 39 Phenergan VC/Codeine, 39 Phenergan w/Dextromethorphan, 39 Phenergan/Codeine, 39 Phenobarbital, 17, 29 Phenoxybenzamine, 25 Phenytek, 17 Phenytoin, 17 Phisohex, 53 PhosLo, 57 Phoslyra, 57 Phosphate Binders, 57 Phospholine Iodide, 42 Phosphorus, 57 Phosphorus Agents, 57 Phrenilin, 14, 15 Phrenilin Forte, 15 Phytonadione, 58 Pigmenting and Miscellaneous Agents, 53 Pilocar, 42 Pilocarpine, 42, 44 Pilocarpine 4% Gel, 42 Pilopine HS, 42 Pimecrolimus, 53 Pindolol, 23 Pioglitazone, 45 Pioglitazone/Glimepiride, 45 Pioglitazone/Metformin, 45 Pirbuterol Acetate, 40 Piroxicam, 13 Pitavastatin, 26 Pituitary Agents, 51 Plan B, 50
Plan B One-Step, 50 Plaquenil, 13, 33 Plavix, 27 Plendil, 24 Pletal, 27 Podofilox, 53 Polycitra Syrup, 51 Polycitra-K Solution, 51 Polycitra-LC Solution, 51 Polyethylene Glycol, 30 Polymyxin/Bacitracin, 41 Polymyxin/Trimethoprim, 41 Poly-Pred, 41 Polysporin Ophthalmic, 41 Polytrim, 41 Poly-Vi-Flor, 59 Ponstel, 13 Potassium Agents, 57 Potassium Chloride 10mEq, 57 Potassium Chloride 20mEq, 57 Potassium Chloride 8mEq, 57 Potassium Chloride Effervescent Tablets 25mEq, 57 Potassium Chloride Effervescent Tablets 50mEq, 57 Potassium Chloride Powder 20mEq, 57 Potassium Citrate, 57 Potassium Iodide, 40 Pradaxa, 27 Pramipexole, 18 Pramipexole ER, 18 Pramlintide, 46 Pramosone, 54 Prandimet, 45 Prandin, 45 Prasugrel, 27 Pravachol, 26 Pravastatin, 26 Praziquantel, 31 Prazosin, 26 Precision, 46, 47 Precision Xtra Test Strips, 47 Precose, 45 Pred Forte, 41 Pred Mild, 42 Pred-G, 41 Prednisolone, 41, 42, 43, 47 Prednisolone Acetate, 41, 42 Prednisolone Acetate 1% Suspension, 41 Prednisolone Phosphate 0.125%, 42 Prednisone, 47 Pregabalin, 17 Prelone, 47 Premarin, 10, 48 Premphase, 48 Prempro, 48
79
Prenatal Multivitamins (generic), 58 Prenatal Vitamin Agents, 58 Prenatal Vitamins (generic), 58 Prevacid (Rx), 29 Prevacid OTC, 29 Prevacid SoluTab, 29 Preven, 50 Prevident 5000 Plus, 58 Prevpac, 30 Prezista, 34 Prilosec (Rx), 29 Prilosec Granules, 29 Prilosec OTC, 29 Primaquine, 33 Primidone, 17 Primsol, 51 Principen, 32 Prinivil, 23 Prinzide, 24 Pristiq, 19 ProAir HFA, 40 Proamatine, 40 Probenecid, 59 Procainamide, 22 Procainamide SR, 22 Procanbid, 22 Procarbazine, 36 Procardia, 24 Procardia XL, 24 Prochieve, 51 Prochlorperazine Maleate, 28 Procrit, 12, 27 Proctocort, 54 Proctocream HC, 54 Proctofoam HC, 54 Procyclidine, 18 Progesterone, 51 Progesterone Vaginal Gel, 51 Progestin Agents, 51 Prograf, 10, 37 Proleukin, 12, 38 Prolia, 48 Prolixin, 20 Proloprim, 51 Promacta, 27 Promethazine, 21, 28, 38, 39 Promethazine VC, 39 Promethazine/Codeine, 39 Promethazine/Dextromethorphan, 39 Promethazine/Phenylephrine, 39 Prometrium, 51 Pronestyl, 22 Propafenone, 22 Propafenone, Extended Release, 22
Propine, 42 Propranolol, 23 Propranolol LA, 23 Propylthiouracil, 46 Proscar, 52 Prosed/DS, 51 Proton Pump Inhibitors, 29 Protonix, 29 Protonix Granules, 29 Protopic, 53 Proventil HFA, 40 Provera, 51 Provigil, 22 Prozac, 19 Prudoxin, 53 Psorcon, 56 Psorcon-E, 56 Psoriatec, 57 Psychotherapeutic Agents, 19 Psychotherapeutic Combination Agents, 20 Pulmicort, 43, 44 Pulmicort Respules 0.25mg/2ml and 0.5mg/2ml, 43 Pulmicort Respules 1mg/2ml, 44 Pulmozyme, 12, 40 Purinethol, 36 Pylera, 30 Pyrazinamide, 33 Pyridium, 51 Pyridostigmine, 19 Pyrimethamine, 33
Q Qualaquin, 33 Questran, 26 Questran Light, 26 Quetiapine, 21 Quetiapine, extended-release, 21 Quinaglute, 22 Quinapril, 23, 24 Quinapril/HCTZ, 24 Quinidine, 22 Quinidine Gluconate, 22 Quinidine Sulfate, 22 Quinine, 33 Quinolones, 32 Quixin, 41 Qvar, 44
R Rabeprazole, 29 Raloxifene, 48 Raltegravir, 35
80
Ramelteon, 21 Ramipril, 23 Ranexa, 28 Ranitidine, 30 Ranolazine, 28 Rapaflo, 52 Rapamune, 38 Rasagiline, 18 Razadyne, 16 Razadyne ER, 16 Rebetol, 34 Rebif, 12, 38 Reclast 5mg/100ml, 48 Rectal Agents, 54 Reglan, 28, 30 Reglan Injection, 28 Regranex, 53 Relafen, 13 Relenza, 34 Relistor, 16 Relpax, 9, 15 Remeron, 19 Remeron Soltab, 19 Remicade, 14 Remodulin, 25 Renagel, 57 Renvela, 57 Repaglinide, 45 Repaglinide/Metformin, 45 Reprexain, 15 Requip, 18 Requip XL, 18 Rescriptor, 34 Reserpine, 23 Respiratory Smooth Muscle Relaxant Agents, 44 Restasis, 43 Restoril, 20 Retapamulin, 54 Retrovir, 34 Revatio Injection, 25 Revatio Tablets, 25 Revia, 16 Revlimid, 12, 36 Reyataz, 34 Rheumatrex, 13, 36 Rhinocort Aqua, 44 Ribavirin, 34 Ribavirin, Aerosolized, 34 Rifabutin, 34 Rifadin, 34 Rifamate, 34 Rifampin, 34 Rifampin/Isoniazid, 34 Rifaximin, 32
Rilpivirine, 35 Rilutek, 18 Riluzole, 18 RimabotulinumtoxinB, 18 Rimantadine, 34 Rimexolone, 42 Riomet, 45 Risedronate, 47 Risedronate, Delayed-Release, 47 Risedronate/Calcium, 47 Risperdal, 20, 21 Risperdal Consta, 21 Risperidone, 20, 21 Risperidone Injection, 21 Ritalin, 21, 22 Ritalin LA, 22 Ritalin SR, 21 Ritonavir, 35 Rituxan, 12, 37 Rituximab, 37 Rivastigmine, 16 Rivastigmine Transdermal, 16 Rizatriptan Succinate, 15 Robaxin, 18 Rocaltrol, 46, 58 Romidepsin, 37 Romiplostim, 27 Ropinirole, 18 Ropinirole ER, 18 Rosiglitazone, 45 Rosiglitazone/Glimepiride, 45 Rosiglitazone/Metformin, 45 Rosuvastatin, 26 Rowasa, 30 Rozerem, 21 Rufinamide, 17 Rynatan, 39 Rythmol, 22 Rythmol SR, 22
S S.S.R.I. Agents, 19 Saizen, 49 Salagen, 44 Salmeterol, 40 Salsalate, 13 Samsca, 12, 58 Sanctura, 51, 52 Sanctura XR, 52 Sandimmune, 37 Sandostatin, 12, 49 Sandostatin LAR, 12, 49 Santyl, 53
81
Saphris, 20 Saquinavir, 34, 35 Sargramostim, 27 Savella, 21 Scabicide/Pediculicide Agents, 57 Scopolamine, 29, 42 Seasonale, 50 Seasonique, 50 Sectral, 23 Sedating Antihistamine Agents, 38 Selective 5-HT3 Receptor Antagonist, 28 Selective Aldosterone Antagonist, 25 Selegiline, 18, 20 Selegiline ODT, 18 Selegiline Transdermal, 20 Selenium Sulfide 2.5%, 56 Selsun, 56 Selzentry, 35 Semprex-D, 39 Sensipar, 58 Septra, 33 Serax, 20 Serevent Diskus, 40 Seroquel, 21 Seroquel XR, 21 Serostim, 49 Sertraline, 19 Serzone, 19 Sevelamer Carbonate, 57 Sevelamer HCl, 57 Sildenafil Citrate, 25, 52 Silodosin, 52 Silvadene, 54 Silver Sulfadiazine, 54 Simponi, 14 Simvastatin, 26 Sinemet, 18 Sinemet CR, 18 Sinequan, 19 Singulair, 9, 44 Sirolimus, 38 Sitagliptin, 45 Sitagliptin/Metformin, 45 Skelaxin, 9, 18 Skeletal Muscle Relaxants, 18 Skelid, 48 Sodium Chloride, 31, 44, 57 Sodium Fluoride, 58 Sodium Fluoride (drops and tablets), 58 Sodium Hyaluronate, 14 Sodium Oxybate, 21 Sodium Polystyrene Sulfonate, 57 Solaraze, 53 Solifenacin, 52
Soma, 18 Soma Compound, 18 Somatostatin Analogs, 49 Somatropin, 49 Somatuline Depot, 12, 49 Somavert, 49 Sonata, 21 Sorafenib, 36 Soriatane, 53 Sotalol, 22 Sotret, 53 Spacers, 44 Spectazole, 54 Spectracef, 31 Spiriva, 40 Spironolactone, 25 Spironolactone/HCTZ, 25 Sporanox, 33 Sprintec, 50 Sprycel, 12, 36 SSKI, 40 Stadol, 16 Stalevo, 18 Starlix, 45 Stavudine (d4T), 35 Stelara, 37 Stelazine, 20 Strattera, 22 Striant, 47 Stromectol, 31 Suboxone 2mg, 16 Suboxone 8mg, 16 Subutex, 16 Succimer, 58 Sucralfate, 29 Sular, 24 Sulconazole, 55 Sulfacetamide 10%, 43 Sulfacetamide 10%/Fluorometholone 0.1%, 43 Sulfacetamide 10%/Prednisolone 0.2%, 43 Sulfacetamide Lotion, 56 Sulfacetamide/Sulfur, 53 Sulfacetamide/Sulfur, Lotion, 53 Sulfacetamide/Sulfur, Wash, 53 Sulfadiazine, 33 Sulfadoxine/Pyrimethamine, 33 Sulfanilamide Compound, 55 Sulfasalazine, 13, 30 Sulfatol, 53 Sulfisoxazole, 33 Sulfonamides, 32 Sulfonylureas, 45 Sulindac, 13 Sumatriptan, 14
82
Sumycin, 33 Sunitinib, 36 Supartz, 12, 14 Suprax, 31 Suprep, 29 Sustiva, 35 Sutent, 12, 36 Sylatron, 36 Symbicort, 40 Symbyax, 20 Symlin, 46 Symmetrel, 17, 34 Synagis, 12, 35 Synalar, 55 Synthroid, 10, 46 Synvisc, 12, 14 Synvisc-One, 12, 14 Syringes, Needles, and Pen Needles, 46 Systemic Stimulant Agents, 21
T Tacrine HCl, 16 Tacrolimus, 37, 53 Tacrolimus Anhydrous, 37 Tadalafil, 25, 52 Tagamet, 30 Tambocor, 22 Tamiflu, 34 Tamoxifen Citrate, 36 Tamsulosin, 52 Tapazole, 46 Tarceva, 12, 36 Targretin, 12, 36, 53 Targretin Gel, 53 Tasigna, 12, 36 Tavist, 38 Taxol, 36 Taxotere, 37 Tazarotene, 53 Tazorac, 9, 53 Tegretol, 16, 17 Tegretol XR 100mg, 17 Tegretol XR 200mg and 400mg, 16 Tekamlo, 24 Tekturna, 23, 25 Tekturna HCT, 25 Telaprevir, 34 Telbivudine, 34 Telithromycin, 31 Temazepam, 20 Temodar, 12, 36, 37 Temodar Injection, 37 Temovate, 56
Temozolomide, 36, 37 Temsirolimus, 37 Tenex, 24 Tenofovir, 35 Tenoretic, 24 Tenormin, 23 Terazol-3, 55 Terazol-7, 55 Terazosin, 26, 52 Terbinafine (oral), 33 Terbinafine (OTC), 54 Terbinafine Spray, 55 Terbutaline Sulfate, 40 Terconazole, 55 Teriparatide, 48 Teslac, 36 Testolactone, 36 Testopel, 47 Testosterone Buccal, 47 Testosterone Cypionate, 47 Testosterone Ethanthate, 47 Testosterone Gel, 47 Testosterone Pellets, 47 Testosterone Topical, 47 Testosterone Topical Solution, 47 Testosterone Transdermal, 47 Tetracycline, 30, 33 Tetracyclines, 33 Tev-Tropin, 12, 49 Thalidomide, 36 Thalomid, 12, 36 Theochron, 45 Theophylline SR, 45 Thiabendazole, 31 Thiazide and Related Diuretics, 25 Thioguanine, 36 Thioridazine, 20 Thiothixene, 20 Thorazine, 20 Thrombopoietin Agonists, 27 Thyroid Agents, 45, 46 Thyroid, Desiccated, 46 Thyroid, Pork, 46 Thyrolar, 46 Tiagabine, 17 Tiazac, 24 Ticlid, 27 Ticlopidine, 27 Tigan, 28 Tikosyn, 12, 22 Tiludronate, 48 Timolol, 23, 42 Timoptic, 42 Timoptic-XE, 42
83
Tindamax, 32 Tinidazole, 32 Tinzaparin, 27 Tioconazole, 55 Tiotropium, 40 Tipranavir, 35 Tizanidine tablet, 18 Tobacco Cessation Agents, 59 Tobi, 31 Tobradex Ointment, 41 Tobradex Suspension, 41 Tobramycin Ointment, 41 Tobramycin Solution, 41 Tobramycin/Dexamethasone, 41 Tobramycin/Loteprednol, 41 Tobrex, 41 Tobrex Ointment, 41 Tocilizumab, 37 Tofranil, 19 Tolazamide, 45 Tolbutamide, 45 Tolinase, 45 Tolmetin Sodium, 13 Tolterodine, 52 Tolvaptan, 58 Topamax 25mg, 17 Topamax 50mg & 100mg, 17 Topical Analgesics, 56 Topical Antibiotic Agents, 54 Topical Antifungal Agents, 54 Topical Antipruritic and Local Anesthetic Agents, 56 Topical Antiseptic, 53 Topical Antiviral Agents, 56 Topicort, 55, 56 Topicort LP, 55 Topiramate, 17 Topotecan, 36, 37 Toprol XL, 23 Toradol, 13 Toremifene, 36 Torisel, 12, 37 Torsemide, 25 Toviaz, 51 Tracleer, 25 Tramadol, 16 Tramadol HCl/APAP, 16 Tramadol, Extended-release, 16 Trandate, 23 Trandolapril, 23 Tranexamic Acid, 27 Transderm-Scop, 29 Tranylcypromine, 19 Trastuzumab, 37 Travatan, 43
Travatan Z, 43 Travoprost, 43 Trazodone, 19, 20 Trazodone, Extended-Release, 20 Treanda, 12, 37 Trental, 27 Treprostinil, 25 Tretinoin, 36, 53 Trexall, 13 Triamcinolone, 40, 44, 54, 55, 56 Triamcinolone 0.1% Paste, 40 Triamcinolone Acetonide, Nasal, 44 Triamcinolone Cream, Lotion, Ointment, 55 Triamcinolone Inhaler, 44 Triamcinolone Spray, 56 Triamcinolone/Nystatin, 54 Triamterene/HCTZ, 25 Tricor, 26 Tricyclic Antidepressant Agents, 19 Tridesilon, 55 Trifluoperazine, 20 Trifluridine, 42 Triglide, 26 Trihexyphenidyl, 18 Trilafon, 20 Trileptal, 17 Trileptal Oral Suspension, 17 Trilisate, 13 Trimethobenzamide, 28 Trimethoprim, 33, 51 Trimox, 32 Tri-Norinyl, 50 Triphasic Oral Contraceptives, 50 Tri-Vi-Flor, 59 Trivora, 50 Trizivir, 35 Tropicamide, 42 Trospium, 51, 52 Trospium XR, 52 Trusopt, 42 Truvada, 35 Tussigon, 39 Tussin DM, 39 Tussionex, 39 Tykerb, 12, 36 Tylenol #2, #3, #4, 15 Tylox, 15 Tysabri, 38 Tyvaso, 25 Tyzeka, 34
U Ulcer Eradication Agents, 30
84
Ulcerative Colitis/Crohns’ Agents, 30 Ulesfia, 57 Ulipristal, 50 Uloric, 59 Ultracet, 16 Ultram, 16 Ultram ER, 16 Ultram ER 300mg, 16 Ultravate, 56 Uniphyl, 45 Uniretic, 24 Unithroid, 46 Univasc, 23 Urea, 53 Urea 40% Cream, Lotion, 53 Urea 50% Cream, Ointment, 53 Urecholine, 52 Urinary Cholinergic Agents, 52 Urinary pH Modifiers, 51 Urised, 51 Urispas, 51 Urocit-K, 57 Urogesic-Blue, 51 Uroxatral, 52 Urso, 30 Urso Forte, 30 Ursodiol, 30 Ustekinumab, 37
V Vagifem, 48 Vaginal Antifungal Agents, 55 Vagistat-1, 55 Valacyclovir, 34 Valcyte, 34 Valganciclovir HCl, 34 Valium, 18, 20 Valproic Acid, 17 Valrubicin, 37 Valsartan, 23, 25 Valsartan/HCTZ, 25 Valstar, 12, 37 Valtrex, 34 Valturna, 25 Vancocin, 32 Vancomycin, 32 Vandetanib, 37 Vanos, 56 Vantin, 31 Vardenafil, 52 Varenicline, 60 Vaseretic, 24 Vasocidin, 43
Vasopressin Antagonist, 58 Vasotec, 23 Vectibix, 12, 37 Vectical, 53 Velcade, 12, 37 Venlafaxine, 19 Venlafaxine ER Tablets, 19 Venlafaxine, Extended Release, 19 Ventavis, 25 Ventolin HFA, 40 Vepesid, 36 Veramyst, 44 Verapamil, 24 Verapamil SR, 24 Verapamil SR Capsules, 24 Verapamil SR Tablets, 24 Verelan, 24 Verelan PM, 24 Vermox, 31 Vesanoid, 36 Vesicare, 52 Vexol, 42 Viagra, 52 Vibramycin, 33 Vibra-Tabs, 33 Vicodin, 15 Vicodin ES, 15 Vicon Forte, 58 Vicoprofen, 15 Victoza, 46 Victrelis, 34 Vidaza, 12, 37 Videx, 34, 35 Videx EC, 34 Vigamox, 41 Vimpat, 17 Vi-Q-Tuss, 39 Viracept, 35 Viramune, 35 Viramune XR, 35 Virazole, 34 Viread, 35 Viroptic, 42 Viscous Xylocaine, 40 Visken, 23 Vistaril, 21, 38 Vitamin A, 58 Vitamin and Fluoride Agents, 58 Vitamin B-12, 58 Vitamin D, 58 Vitamin K Activity Agents, 58 Vivaglobin, 38 Vivelle, 48 Vivelle-Dot, 48
85
Vivitrol, 16 Voltaren, 13, 41, 56 Voltaren Gel, 56 Vorinostat, 37 Vosol, 43 Vosol HC, 43 VoSpire ER, 40 Votrient, 12, 36 Vytorin, 26 Vyvanse, 22
W Warfarin, 27 Welchol, 26 Wellbutrin, 19 Wellbutrin SR, 19 Wellbutrin XL, 19 Westcort, 55
X Xalatan, 43 Xanax, 20 Xeloda, 12, 36 Xeomin, 18 Xgeva, 48 Xibrom, 41 Xifaxan, 32 Xolair, 44 Xopenex, 40 Xopenex HFA, 40 Xylocaine, 56 Xyrem, 21 Xyzal, 39
Y Yasmin, 49 Yaz, 49 Yervoy, 37 Yodoxin, 31 Yohimbine, 26 Yovital, 26
Z Zaditor (OTC), 43 Zafirlukast, 44 Zalcitabine (ddC), 35 Zaleplon, 21 Zanaflex Tablet, 18 Zanamivir, 34
Zantac, 30 Zarontin, 17 Zaroxolyn, 26 Zebeta, 23 Zelapar, 18 Zenpep, 30 Zerit, 35 Zestoretic, 24 Zestril, 23 Zetia, 26 Ziac, 24 Ziagen, 34 Zidovudine (AZT), 34 Zidovudine/Lamivudine, 35 Ziprasidone HCl, 21 Zithromax, 31 Zmax, 32 Zocor, 26 Zofran ODT, 28 Zofran Solution, 28 Zofran Tablet, 28 Zoladex, 37 Zoledronic Acid, 48 Zolinza, 12, 37 Zolmitriptan, 15 Zoloft, 19 Zolpidem, 21 Zolpidem, Sublingual, 21 Zometa 4mg/5ml, 48 Zomig Nasal, 15 Zomig/Zomig ZMT, 15 Zonegran, 17 Zonisamide, 17 Zortress, 12, 36 Zovia, 49 Zovirax Cream, 56 Zovirax Ointment, 56 Zovirax Oral, 34 Zyban, 59 Zylet, 41 Zyloprim, 59 Zymar, 41 Zymaxid, 41 Zyprexa, 20, 21 Zyprexa Relprevv, 21 Zyprexa Zydis, 21 Zyrtec OTC, 38 Zyrtec Rx, 38 Zyrtec-D OTC, 39 Zyrtec-D Rx, 39 Zytiga, 36 Zyvox, 32
86
