2021 preventive medications and your plan

2021 Preventive medications and your plan

Managing your health with preventive medications

Your pharmacy benefit plan includes special coverage for preventive medications. These medications help protect against or manage a medical condition, such as:

• Preventing blood clots and reducing the risk of a stroke

• Preventing heart disease and reducing high blood pressure

• Preventing osteoporosis (a disease that leads to an increased risk of bone fracture)

Your health is important. Taking preventive medications as told by your healthcare provider can help you avoid serious illness and high healthcare costs.

In this drug list, brand-name medications are shown in UPPERCASE (for example, LANOXIN) and generic medications in lowercase (for example, digoxin).

Special coverage for preventive medications

The drugs on your plan’s preventive medications list do not have a deductible. This means you’ll pay your copayment/coinsurance or nothing at all, depending on your plan. It can save you money and get the medications you need to help you live a healthier life.

Preventive medications are a group of products in your plan’s formulary which tells you what medications your plan covers.

Please note that most medications on the formulary have a deductible, but preventive medications do not. To check the cost of any medication, see your benefit handbook or contact customer service at the member phone number on your ID card.

Potential savings with generic medications

To get the most from your benefits, ask your doctor if a generic medication is right for you. Generics normally cost less than brand medications, and the Food and Drug Administration (FDA) requires them to be just as safe and effective.

Quality drives our decisions

A group of doctors and pharmacists meets often to review medications and coverage under pharmacy benefit plans. They also suggest which medications should be on your plan’s preventive medications list.

A list of covered preventive medications begins on the next page. Medications are listed by therapeutic category. For questions on injectable preventive medications administered by your doctor or healthcare provider, please call the number on your ID card.

Table of Contents

Analgesics - Drugs for Pain.............................. 4Anti-Addiction / Substance Abuse Treatment

Agents............................................................ 4Anticoagulants.................................................. 4Anticonvulsants - Drugs for Seizures................4Antidepressants................................................ 5Antiemetics - Drugs for Nausea and Vomiting..5Antineoplastics - Drugs for Cancer................... 5Antiparasitics.................................................... 6Antiplatelets...................................................... 6Antipsychotics - Drugs for Mood Disorders...... 6Antivirals........................................................... 6Anxiolytics - Drugs for Anxiety.......................... 7Bipolar Agents - Drugs for Mood Disorders...... 7Cardiovascular Agents - Drugs for Heart and

Circulation Conditions.....................................8Central Nervous System Agents -

Miscellaneous...............................................11Diabetes - Antidiabetic Agents........................11Diabetes - Glucose Monitoring....................... 12Diabetes - Insulins.......................................... 12Gastrointestinal Agents - Drugs for Acid

Reflux and Ulcer........................................... 12Gastrointestinal Agents - Drugs for Bowel,

Intestine and Stomach Conditions................12Genitourinary Agents - Drugs for Prostate

Conditions.....................................................13Hormonal Agents - Osteoporosis....................13Hormonal Agents - Sex Hormones and Birth

Control.......................................................... 13Immunological Agents - Drugs for Immune

System Stimulation or Suppression..............16Metabolic Bone Disease Agents - Drugs for

Osteoporosis................................................ 16Metabolic Bone Disease Agents - Other.........16Miscellaneous Therapeutic Agents.................16Respiratory Tract / Pulmonary Agents -

Drugs for Asthma and Other Lung Conditions 16

Index of Drugs................................................ 18

3

Drug Name

Analgesics - Drugs for Pain

BELBUCA

BUPRENEX

buprenorphine

buprenorphine hcl

BUTRANS

pentazocine-naloxone hcl

PROBUPHINE IMPLANT KIT

Anti-Addiction / Substance Abuse Treatment Agents

BUNAVAIL

buprenorphine hcl

buprenorphine hcl-naloxone hcl

bupropion hcl er (smoking det)

CHANTIX

CHANTIX CONTINUING MONTH PAK

CHANTIX STARTING MONTH PAK

NICOTROL

NICOTROL NS

SUBLOCADE

ZUBSOLV

Anticoagulants

ANGIOMAX

argatroban

ARIXTRA

bivalirudin trifluoroacetate

ELIQUIS

ELIQUIS DVT/PE STARTER PACK

enoxaparin sodium

fondaparinux sodium

FRAGMIN

heparin (porcine) in nacl intravenous solution

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 2500-0.9 UT/500ML-%, 30000-0.9 UNIT/L-%, 500-0.9 UT/500ML-%, 5000-0.9 UNIT/L-%, 5000-0.9 UT/500ML-%

heparin sod (porcine) in d5w

heparin sodium (porcine)

Drug Name

heparin sodium (porcine) pf

jantoven

LOVENOX

PRADAXA

SAVAYSA

warfarin sodium

XARELTO

XARELTO STARTER PACK

Anticonvulsants - Drugs for Seizures

APTIOM

BANZEL

BRIVIACT

carbamazepine

carbamazepine er

CELONTIN

CEREBYX

clobazam

DIACOMIT

DIASTAT ACUDIAL

DIASTAT PEDIATRIC

diazepam

DILANTIN

divalproex sodium

divalproex sodium er

EPIDIOLEX

epitol

ethosuximide

felbamate

FELBATOL

fosphenytoin sodium

FYCOMPA

gabapentin

GABITRIL

lamotrigine

lamotrigine er

lamotrigine starter kit-blue

lamotrigine starter kit-green

lamotrigine starter kit-orange

*Liquid dosage forms for pediatrics only. PA required for all others.

4

Drug Name

levetiracetam

levetiracetam er

levetiracetam in nacl

MYSOLINE

NEMBUTAL

oxcarbazepine

PEGANONE

pentobarbital sodium

phenobarbital

phenobarbital sodium

PHENYTEK

phenytoin

phenytoin infatabs

phenytoin sodium

phenytoin sodium extended

primidone

roweepra

roweepra xr

rufinamide

subvenite

subvenite starter kit-blue

subvenite starter kit-green

subvenite starter kit-orange

SYMPAZAN

tiagabine hcl

topiramate

valproate sodium

valproic acid

vigabatrin

vigadrone

VIMPAT

ZARONTIN

zonisamide

Antidepressants

bupropion hcl

bupropion hcl er (sr)

bupropion hcl er (xl)

citalopram hydrobromide

Drug Name

DESVENLAFAXINE ER

desvenlafaxine succinate er

duloxetine hcl

escitalopram oxalate

FETZIMA

fluoxetine hcl

fluvoxamine maleate

fluvoxamine maleate er

maprotiline hcl

nefazodone hcl

olanzapine-fluoxetine hcl

paroxetine hcl

paroxetine hcl er

PAXIL

sertraline hcl

SYMBYAX

trazodone hcl

TRINTELLIX

venlafaxine hcl

venlafaxine hcl er

VIIBRYD

VIIBRYD STARTER PACK

Antiemetics - Drugs for Nausea and Vomiting

compro

perphenazine

prochlorperazine

prochlorperazine edisylate

prochlorperazine maleate

Antineoplastics - Drugs for Cancer

anastrozole

AROMASIN

exemestane

FARESTON

FEMARA

letrozole

SOLTAMOX

tamoxifen citrate

toremifene citrate


5

Drug Name

Antiparasitics

ARAKODA

atovaquone-proguanil hcl

chloroquine phosphate

COARTEM

DARAPRIM

hydroxychloroquine sulfate

KRINTAFEL

MALARONE

mefloquine hcl

primaquine phosphate

pyrimethamine

QUALAQUIN

quinine sulfate

Antiplatelets

aspirin-dipyridamole er

BRILINTA

cilostazol

clopidogrel bisulfate

dipyridamole

EFFIENT

KENGREAL

prasugrel hcl

ZONTIVITY

Antipsychotics - Drugs for Mood Disorders

ABILIFY MAINTENA

ADASUVE

aripiprazole

ARISTADA

ARISTADA INITIO

CAPLYTA

chlorpromazine hcl

clozapine

CLOZARIL

FANAPT

FANAPT TITRATION PACK

fluphenazine decanoate

fluphenazine hcl

Drug Name

GEODON

HALDOL

HALDOL DECANOATE

haloperidol

haloperidol decanoate

haloperidol lactate

INVEGA

INVEGA SUSTENNA

INVEGA TRINZA

LATUDA

loxapine succinate

molindone hcl

NUPLAZID

olanzapine

paliperidone er

PERSERIS

quetiapine fumarate

quetiapine fumarate er

REXULTI

RISPERDAL CONSTA

risperidone

SAPHRIS

thioridazine hcl

thiothixene

trifluoperazine hcl

VERSACLOZ

VRAYLAR

ziprasidone hcl

ziprasidone mesylate

ZYPREXA RELPREVV

ZYPREXA ZYDIS

Antivirals

abacavir sulfate

abacavir sulfate-lamivudine

abacavir-lamivudine-zidovudine

APTIVUS

atazanavir sulfate

BIKTARVY


6

Drug Name

CIMDUO

COMBIVIR

COMPLERA

CRIXIVAN

DELSTRIGO

didanosine

DOVATO

EDURANT

efavirenz

efavirenz-emtricitab-tenofovir

efavirenz-lamivudine-tenofovir

emtricitabine

emtricitabine-tenofovir df

EMTRIVA ORAL CAPSULE

EMTRIVA ORAL SOLUTION

EPIVIR

EPZICOM

EVOTAZ

fosamprenavir calcium

FUZEON

GENVOYA

INTELENCE

INVIRASE

ISENTRESS

ISENTRESS HD

JULUCA

KALETRA ORAL SOLUTION

KALETRA ORAL TABLET

lamivudine

lamivudine-zidovudine

LEXIVA ORAL SUSPENSION

LEXIVA ORAL TABLET

lopinavir-ritonavir

nevirapine

nevirapine er

NORVIR ORAL PACKET

NORVIR ORAL SOLUTION

NORVIR ORAL TABLET

Drug Name

ODEFSEY

PIFELTRO

PREZCOBIX

PREZISTA

RETROVIR INTRAVENOUS

RETROVIR ORAL

REYATAZ ORAL CAPSULE

REYATAZ ORAL PACKET

ritonavir

RUKOBIA

SELZENTRY

stavudine

STRIBILD

SUSTIVA

SYMFI

SYMFI LO

SYMTUZA

tenofovir disoproxil fumarate

TIVICAY

TIVICAY PD

TRIUMEQ

TRIZIVIR

TROGARZO

TYBOST

VIRACEPT

VIRAMUNE

VIRAMUNE XR

VIREAD ORAL POWDER

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

VIREAD ORAL TABLET 300 MG

ZIAGEN

zidovudine

Anxiolytics - Drugs for Anxiety

clonazepam

Bipolar Agents - Drugs for Mood Disorders

EQUETRO


7

Drug Name

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL

ACCURETIC

acebutolol hcl

ALDACTAZIDE

ALDACTONE

aliskiren fumarate

amiloride hcl

amiloride-hydrochlorothiazide

amiodarone hcl

amlodipine besylate

amlodipine besylate-benazepril hcl

amlodipine besylate-valsartan

amlodipine-atorvastatin

amlodipine-olmesartan

amlodipine-valsartan-hctz

ATACAND HCT

atenolol

atenolol-chlorthalidone

atorvastatin calcium

AVALIDE

benazepril hcl

benazepril-hydrochlorothiazide

BETAPACE

BETAPACE AF

betaxolol hcl

BIDIL

bisoprolol fumarate

bisoprolol-hydrochlorothiazide

BREVIBLOC

BREVIBLOC IN NACL

BREVIBLOC PREMIXED

BREVIBLOC PREMIXED DS

bumetanide

BUMEX

BYSTOLIC

CADUET

Drug Name

CALAN SR

candesartan cilexetil

candesartan cilexetil-hctz

captopril

captopril-hydrochlorothiazide

CARDENE IV

CARDIZEM

CARDIZEM CD

CARDIZEM LA

CARDURA

cartia xt

carvedilol

carvedilol phosphate er

CATAPRES

chlorothiazide sodium

chlorthalidone

cholestyramine

cholestyramine light

CLEVIPREX

clonidine

clonidine hcl

colesevelam hcl

colestipol hcl

CORGARD

CORVERT

DEMSER

DIBENZYLINE

digitek

digox

digoxin

DILATRATE-SR

diltiazem hcl

diltiazem hcl er

diltiazem hcl er beads

diltiazem hcl er coated beads

DILTIAZEM HCL-DEXTROSE

DILTIAZEM HCL-SODIUM CHLORIDE

dilt-xr


8

Drug Name

DIURIL

dofetilide

doxazosin mesylate

DYRENIUM

EDARBI

EDARBYCLOR

EDECRIN

enalapril maleate

enalaprilat

enalapril-hydrochlorothiazide

eplerenone

esmolol hcl intravenous solution 100 mg/10ml

ESMOLOL HCL INTRAVENOUS SOLUTION 2000 MG/100ML, 2500 MG/250ML

esmolol hcl-sodium chloride

ethacrynate sodium

ethacrynic acid

EZALLOR SPRINKLE

ezetimibe

ezetimibe-simvastatin

felodipine er

fenofibrate

fenofibrate micronized

fenofibric acid

FENOGLIDE

FIBRICOR

flecainide acetate

FLOLIPID

fluvastatin sodium

fluvastatin sodium er

fosinopril sodium

fosinopril sodium-hctz

furosemide

FUROSEMIDE IN SODIUM CHLORIDE

gemfibrozil

GONITRO

guanfacine hcl

HEMANGEOL

Drug Name

hydralazine hcl

hydrochlorothiazide

ibutilide fumarate

indapamide

INSPRA

irbesartan

irbesartan-hydrochlorothiazide

isoproterenol hcl

ISORDIL TITRADOSE

isosorbide dinitrate

isosorbide mononitrate

isosorbide mononitrate er

isradipine

ISUPREL

JUXTAPID

LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE

labetalol hcl oral

LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS

labetalol hcl solution 5 mg/ml intravenous

LANOXIN INJECTION

LANOXIN ORAL

LANOXIN PEDIATRIC

LIPOFEN

lisinopril

lisinopril-hydrochlorothiazide

LOPID

LOPRESSOR

LOPRESSOR HCT

losartan potassium

losartan potassium-hctz

LOTENSIN

LOTENSIN HCT

lovastatin

matzim la

MAXZIDE

MAXZIDE-25


9

Drug Name

methyldopa

methyldopa-hydrochlorothiazide

metolazone

metoprolol succinate er

metoprolol tartrate

metoprolol-hydrochlorothiazide

metyrosine

milrinone lactate

milrinone lactate in dextrose

MINIPRESS

minitran

minoxidil

moexipril hcl

MULTAQ

nadolol

NEXLETOL

NEXLIZET

NEXTERONE

niacin er (antihyperlipidemic)

nicardipine hcl

NICARDIPINE HCL IN NACL

nifedipine

nifedipine er

nifedipine er osmotic release

nimodipine

nisoldipine er

NITRO-BID

NITRO-DUR

nitroglycerin

nitroglycerin in d5w

NITROLINGUAL

NITROMIST

NITROPRESS

nitroprusside sodium

NITRO-TIME

NYMALIZE

olmesartan medoxomil

olmesartan medoxomil-hctz

Drug Name

olmesartan-amlodipine-hctz

PACERONE ORAL TABLET 100 MG

pacerone tablet 400 mg oral

PACERONE TABLET 400 MG ORAL

perindopril erbumine

phenoxybenzamine hcl

phentolamine mesylate

pindolol

PRALUENT

pravastatin sodium

prazosin hcl

PRESTALIA

prevalite

PROCARDIA

PROCARDIA XL

propafenone hcl

propafenone hcl er

propranolol hcl

propranolol hcl er

propranolol-hctz

quinapril hcl

quinapril-hydrochlorothiazide

ramipril

ranolazine er

REPATHA

REPATHA PUSHTRONEX SYSTEM

REPATHA SURECLICK

rosuvastatin calcium

RYTHMOL SR

simvastatin

SODIUM DIURIL

SODIUM EDECRIN

sodium nitroprusside

sorine

sotalol hcl (af)

SOTALOL HCL INTRAVENOUS

sotalol hcl oral

SOTYLIZE


10

Drug Name

spironolactone

spironolactone-hctz

SULAR

TARKA

taztia xt

TEKTURNA

TEKTURNA HCT

telmisartan

telmisartan-amlodipine

telmisartan-hctz

TENORETIC 100

TENORETIC 50

tiadylt er

TIAZAC

timolol maleate

torsemide

trandolapril

trandolapril-verapamil hcl er

triamterene

triamterene-hctz

TRILIPIX

TWYNSTA

valsartan

valsartan-hydrochlorothiazide

VASERETIC

VASOTEC

VECAMYL

verapamil hcl

verapamil hcl er

VERELAN

VERELAN PM

ZESTORETIC

ZIAC

Central Nervous System Agents - Miscellaneous

pregabalin

Diabetes - Antidiabetic Agents

acarbose

Drug Name

ACTOPLUS MET

ACTOS

AMARYL

AVANDIA

BYDUREON

BYDUREON BCISE AUTOINJECTOR

BYETTA 10 MCG PEN

BYETTA 5 MCG PEN

CYCLOSET

DUETACT

FARXIGA

glimepiride

glipizide ir

glipizide er

glipizide xl

glipizide-metformin hcl

GLUCOTROL

GLUCOTROL XL

glyburide

glyburide micronized

glyburide-metformin

GLYNASE

GLYSET

GLYXAMBI

JANUMET

JANUMET XR

JANUVIA

JARDIANCE

JENTADUETO

JENTADUETO XR

metformin hcl ir

metformin hcl er

miglitol

nateglinide

OZEMPIC

pioglitazone hcl

pioglitazone hcl-glimepiride

pioglitazone hcl-metformin hcl


11

Drug Name

PRECOSE

repaglinide

RIOMET

RIOMET ER

RYBELSUS

SOLIQUA

STARLIX

SYMLINPEN 120

SYMLINPEN 60

SYNJARDY

SYNJARDY XR

tolbutamide

TRADJENTA

TRIJARDY XR

TRULICITY

VICTOZA

XIGDUO XR

XULTOPHY

Diabetes - Glucose Monitoring

CONTOUR CONTROL

CONTOUR NEXT CONTROL

CONTOUR NEXT LINK

CONTOUR NEXT MONITOR

CONTOUR NEXT TEST

CONTOUR TEST

Diabetes - Insulins

AFREZZA

HUMALOG KWIKPEN

HUMALOG MIX 50/50 KWIKPEN

HUMALOG MIX 50/50 VIAL

HUMALOG MIX 75/25 KWIKPEN

HUMALOG MIX 75/25 VIAL

HUMALOG U-100 JUNIOR KWIKPEN

HUMALOG VIAL

HUMULIN 70/30 KWIKPEN

HUMULIN 70/30 VIAL

HUMULIN N KWIKPEN

HUMULIN N VIAL

Drug Name

HUMULIN R U-500 KWIKPEN

HUMULIN R U-500 VIAL

HUMULIN R VIAL

LANTUS SOLOSTAR

LANTUS U-100 VIAL

LEVEMIR U-100 FLEXTOUCH

LEVEMIR U-100 VIAL

LYUMJEV

LYUMJEV KWIKPEN

MYXREDLIN

TOUJEO MAX SOLOSTAR

TOUJEO SOLOSTAR

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

CARAFATE

CYTOTEC

famotidine

misoprostol

nizatidine

sucralfate

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

amoxicill-clarithro-lansopraz

CLENPIQ

gavilyte-c

gavilyte-g

gavilyte-h

gavilyte-n with flavor pack

HELIDAC THERAPY

OMECLAMOX-PAK

peg 3350-kcl-na bicarb-nacl

peg-3350/electrolytes

peg-3350/electrolytes/ascorbat

peg-kcl-nacl-nasulf-na asc-c

peg-prep

PYLERA

SUPREP BOWEL PREP KIT

TALICIA


12

Drug Name

trilyte

Genitourinary Agents - Drugs for Prostate Conditions

terazosin hcl

Hormonal Agents - Osteoporosis

EVISTA

OSPHENA

raloxifene hcl

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA

afirmelle

ALORA

altavera

alyacen 1/35

alyacen 7/7/7

amabelz

amethia

amethia lo

amethyst

ANGELIQ

apri

aranelle

ashlyna

aubra

aubra eq

aurovela 1.5/30

aurovela 1/20

aurovela 24 fe

aurovela fe 1.5/30

aurovela fe 1/20

aviane

ayuna

azurette

balziva

bekyree

BIJUVA

blisovi 24 fe

blisovi fe 1.5/30

Drug Name

blisovi fe 1/20

briellyn

camila

camrese

camrese lo

caziant

charlotte 24 fe

chateal

chateal eq

CLIMARA PRO

COMBIPATCH

cryselle-28

cyclafem 1/35

cyclafem 7/7/7

cyred

cyred eq

dasetta 1/35

dasetta 7/7/7

daysee

deblitane

DELESTROGEN

delyla

DEPO-ESTRADIOL

DEPO-PROVERA

DEPO-SUBQ PROVERA 104

desogestrel-ethinyl estradiol

DIVIGEL

dotti

drospiren-eth estrad-levomefol

drospirenone-ethinyl estradiol

DUAVEE

ELESTRIN

elinest

ELLA

eluryng

emoquette

enpresse-28

enskyce


13

Drug Name

errin

estarylla

estradiol

estradiol valerate

estradiol-norethindrone acet

ESTROGEL

ESTROSTEP FE

ethynodiol diac-eth estradiol

etonogestrel-ethinyl estradiol

EVAMIST

falmina

fayosim

FEMHRT LOW DOSE

femynor

fyavolv

gianvi

hailey 1.5/30

hailey 24 fe

hailey fe 1.5/30

hailey fe 1/20

heather

incassia

introvale

isibloom

jaimiess

jasmiel

jencycla

jinteli

jolessa

juleber

junel 1.5/30

junel 1/20

junel fe 1.5/30

junel fe 1/20

junel fe 24

kaitlib fe

kalliga

kariva

Drug Name

kelnor 1/35

kelnor 1/50

kurvelo

KYLEENA

larin 1.5/30

larin 1/20

larin 24 fe

larin fe 1.5/30

larin fe 1/20

larissia

layolis fe

leena

lessina

levonest

levonorgest-eth est & eth est

levonorgest-eth estrad 91-day

levonorgestrel-ethinyl estrad

levonorg-eth estrad triphasic

levora 0.15/30 (28)

LILETTA (52 MG)

lillow

lojaimiess

loryna

LOSEASONIQUE

low-ogestrel

lo-zumandimine

lutera

lyza

marlissa

medroxyprogesterone acetate

melodetta 24 fe

MENEST

MENOSTAR

mibelas 24 fe

microgestin 1.5/30

microgestin 1/20

microgestin fe 1.5/30

microgestin fe 1/20


14

Drug Name

mili

mimvey

MINIVELLE

MIRCETTE

MIRENA (52 MG)

mono-linyah

NATAZIA

necon 0.5/35 (28)

nikki

nora-be

norethin ace-eth estrad-fe

norethindrone

norethindrone acet-ethinyl est

norethindrone-eth estradiol

norethin-eth estradiol-fe

norgestimate-eth estradiol

norgestimate-ethinyl estradiol triphasic

norlyda

norlyroc

nortrel 0.5/35 (28)

nortrel 1/35 (21)

nortrel 1/35 (28)

nortrel 7/7/7

NUVARING

ocella

ORIAHNN

orsythia

PARAGARD INTRAUTERINE COPPER

philith

pimtrea

pirmella 1/35

pirmella 7/7/7

portia-28

PREFEST

PREMARIN INJECTION

PREMARIN ORAL

PREMPHASE

PREMPRO

Drug Name

previfem

QUARTETTE

reclipsen

rivelsa

setlakin

sharobel

simliya

simpesse

SKYLA

sprintec 28

sronyx

syeda

tarina 24 fe

tarina fe 1/20

tarina fe 1/20 eq

tilia fe

tri femynor

tri-estarylla

tri-legest fe

tri-linyah

tri-lo-estarylla

tri-lo-marzia

tri-lo-mili

tri-lo-sprintec

tri-mili

tri-previfem

tri-sprintec

trivora (28)

tri-vylibra

tri-vylibra lo

tulana

TWIRLA

tyblume

tydemy

velivet

vienva

viorele

volnea


15

Drug Name

vyfemla

vylibra

wera

wymzya fe

xulane

zarah

zovia 1/35e (28)

zumandimine

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ASTAGRAF XL

AZASAN

azathioprine

azathioprine sodium

CELLCEPT

CELLCEPT INTRAVENOUS

cyclosporine

cyclosporine modified

ENVARSUS XR

everolimus

gengraf

IMURAN

mycophenolate mofetil

mycophenolate mofetil hcl

mycophenolate sodium

MYFORTIC

NEORAL

PROGRAF

RAPAMUNE

SANDIMMUNE INTRAVENOUS

SANDIMMUNE ORAL CAPSULE

SANDIMMUNE ORAL SOLUTION

sirolimus

tacrolimus

ZORTRESS

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL

Drug Name

alendronate sodium

ATELVIA

BINOSTO

BONIVA

calcitonin (salmon)

EVENITY

FORTEO

FOSAMAX

ibandronate sodium

MIACALCIN

pamidronate disodium

RECLAST

risedronate sodium

TERIPARATIDE (RECOMBINANT)

TYMLOS

zoledronic acid

Metabolic Bone Disease Agents - Other

NATPARA

Miscellaneous Therapeutic Agents

heparin lock flush

heparin sodium lock flush

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE

ADVAIR DISKUS

ADVAIR HFA

albuterol sulfate

albuterol sulfate er

albuterol sulfate hfa

aminophylline

ANORO ELLIPTA

ARCAPTA NEOHALER

ARNUITY ELLIPTA

ATROVENT HFA

BREO ELLIPTA

BROVANA

budesonide

COMBIVENT RESPIMAT


16

Drug Name

cromolyn sodium

DALIRESP

difil-g forte

ELIXOPHYLLIN

FLOVENT DISKUS

FLOVENT HFA

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

ipratropium bromide

ipratropium-albuterol

levalbuterol hcl

LONHALA MAGNAIR REFILL KIT

LONHALA MAGNAIR STARTER KIT

metaproterenol sulfate

montelukast sodium

PERFOROMIST

PULMICORT FLEXHALER

SEREVENT DISKUS

SPIRIVA HANDIHALER

SPIRIVA RESPIMAT

STIOLTO RESPIMAT

STRIVERDI RESPIMAT

SYMBICORT

terbutaline sulfate

THEO-24

theophylline

theophylline er

theophylline in d5w

TRELEGY ELLIPTA

wixela inhub

XOPENEX

XOPENEX CONCENTRATE

YUPELRI

zafirlukast

Drug Name

zileuton er


17

Index of Drugs

abacavir sulfate.....................6abacavir sulfate-lamivudine.. 6abacavir-lamivudine-zidovudine.............................6ABILIFY MAINTENA.............6acarbose............................. 11ACCOLATE........................ 16ACCUPRIL............................8ACCURETIC.........................8acebutolol hcl........................8ACTIVELLA........................ 13ACTONEL...........................16ACTOPLUS MET................11ACTOS............................... 11ADASUVE.............................6ADVAIR DISKUS................ 16ADVAIR HFA...................... 16afirmelle.............................. 13AFREZZA........................... 12albuterol sulfate.................. 16albuterol sulfate er.............. 16albuterol sulfate hfa............ 16ALDACTAZIDE..................... 8ALDACTONE........................8alendronate sodium............ 16aliskiren fumarate................. 8ALORA................................13altavera............................... 13alyacen 1/35....................... 13alyacen 7/7/7...................... 13amabelz.............................. 13AMARYL............................. 11amethia............................... 13amethia lo........................... 13amethyst............................. 13amiloride hcl..........................8amiloride-hydrochlorothiazide...............8aminophylline......................16amiodarone hcl..................... 8amlodipine besylate.............. 8amlodipine besylate-benazepril hcl........................8amlodipine besylate-valsartan............................... 8amlodipine-atorvastatin.........8amlodipine-olmesartan......... 8amlodipine-valsartan-hctz.....8amoxicill-clarithro-lansopraz............................ 12anastrozole........................... 5ANGELIQ............................13ANGIOMAX.......................... 4

ANORO ELLIPTA............... 16apri......................................13APTIOM................................ 4APTIVUS.............................. 6ARAKODA............................ 6aranelle............................... 13ARCAPTA NEOHALER...... 16argatroban............................ 4aripiprazole........................... 6ARISTADA............................6ARISTADA INITIO................ 6ARIXTRA.............................. 4ARNUITY ELLIPTA.............16AROMASIN...........................5ashlyna............................... 13aspirin-dipyridamole er......... 6ASTAGRAF XL................... 16ATACAND HCT.................... 8atazanavir sulfate..................6ATELVIA............................. 16atenolol................................. 8atenolol-chlorthalidone..........8atorvastatin calcium.............. 8atovaquone-proguanil hcl..... 6ATROVENT HFA................ 16aubra...................................13aubra eq..............................13aurovela 1.5/30................... 13aurovela 1/20...................... 13aurovela 24 fe..................... 13aurovela fe 1.5/30............... 13aurovela fe 1/20.................. 13AVALIDE...............................8AVANDIA............................ 11aviane................................. 13ayuna.................................. 13AZASAN............................. 16azathioprine........................ 16azathioprine sodium............16azurette...............................13balziva.................................13BANZEL................................4bekyree............................... 13BELBUCA............................. 4benazepril hcl........................8benazepril-hydrochlorothiazide...............8BETAPACE...........................8BETAPACE AF..................... 8betaxolol hcl..........................8BIDIL.....................................8BIJUVA............................... 13BIKTARVY............................ 6

BINOSTO............................16bisoprolol fumarate............... 8bisoprolol-hydrochlorothiazide...............8bivalirudin trifluoroacetate.....4blisovi 24 fe.........................13blisovi fe 1.5/30...................13blisovi fe 1/20......................13BONIVA.............................. 16BREO ELLIPTA.................. 16BREVIBLOC......................... 8BREVIBLOC IN NACL.......... 8BREVIBLOC PREMIXED..... 8BREVIBLOC PREMIXED DS.........................................8briellyn................................ 13BRILINTA..............................6BRIVIACT............................. 4BROVANA.......................... 16budesonide......................... 16bumetanide........................... 8BUMEX................................. 8BUNAVAIL............................ 4BUPRENEX.......................... 4buprenorphine.......................4buprenorphine hcl................. 4buprenorphine hcl-naloxone hcl..........................4bupropion hcl........................ 5bupropion hcl er (smoking det)........................................4bupropion hcl er (sr)..............5bupropion hcl er (xl).............. 5BUTRANS.............................4BYDUREON....................... 11BYDUREON BCISE AUTOINJECTOR................11BYETTA 10 MCG PEN....... 11BYETTA 5 MCG PEN......... 11BYSTOLIC............................ 8CADUET............................... 8CALAN SR............................8calcitonin (salmon)..............16camila................................. 13camrese.............................. 13camrese lo.......................... 13candesartan cilexetil ............. 8candesartan cilexetil-hctz..... 8CAPLYTA............................. 6captopril ................................ 8captopril-hydrochlorothiazide...............8CARAFATE.........................12

18

carbamazepine..................... 4carbamazepine er................. 4CARDENE IV........................8CARDIZEM........................... 8CARDIZEM CD.....................8CARDIZEM LA......................8CARDURA............................ 8cartia xt................................. 8carvedilol...............................8carvedilol phosphate er.........8CATAPRES.......................... 8caziant................................ 13CELLCEPT......................... 16CELLCEPT INTRAVENOUS..................16CELONTIN............................4CEREBYX.............................4CHANTIX.............................. 4CHANTIX CONTINUING MONTH PAK........................ 4CHANTIX STARTING MONTH PAK........................ 4charlotte 24 fe..................... 13chateal................................ 13chateal eq........................... 13chloroquine phosphate......... 6chlorothiazide sodium........... 8chlorpromazine hcl................6chlorthalidone....................... 8cholestyramine......................8cholestyramine light.............. 8cilostazol............................... 6CIMDUO............................... 7citalopram hydrobromide...... 5CLENPIQ............................ 12CLEVIPREX..........................8CLIMARA PRO................... 13clobazam.............................. 4clonazepam.......................... 7clonidine................................8clonidine hcl.......................... 8clopidogrel bisulfate.............. 6clozapine...............................6CLOZARIL............................ 6COARTEM............................6colesevelam hcl.................... 8colestipol hcl......................... 8COMBIPATCH....................13COMBIVENT RESPIMAT... 16COMBIVIR............................ 7COMPLERA..........................7compro..................................5CONTOUR CONTROL....... 12

CONTOUR NEXT CONTROL.......................... 12CONTOUR NEXT LINK...... 12CONTOUR NEXT MONITOR...........................12CONTOUR NEXT TEST.....12CONTOUR TEST............... 12CORGARD........................... 8CORVERT............................ 8CRIXIVAN.............................7cromolyn sodium.................17cryselle-28.......................... 13cyclafem 1/35......................13cyclafem 7/7/7.....................13CYCLOSET........................ 11cyclosporine........................16cyclosporine modified......... 16cyred................................... 13cyred eq.............................. 13CYTOTEC...........................12DALIRESP.......................... 17DARAPRIM...........................6dasetta 1/35........................ 13dasetta 7/7/7....................... 13daysee................................ 13deblitane............................. 13DELESTROGEN.................13DELSTRIGO......................... 7delyla.................................. 13DEMSER.............................. 8DEPO-ESTRADIOL............ 13DEPO-PROVERA...............13DEPO-SUBQ PROVERA 104......................................13desogestrel-ethinyl estradiol.............................. 13DESVENLAFAXINE ER........5desvenlafaxine succinate er...........................................5DIACOMIT............................ 4DIASTAT ACUDIAL.............. 4DIASTAT PEDIATRIC.......... 4diazepam.............................. 4DIBENZYLINE...................... 8didanosine............................ 7difil-g forte........................... 17digitek................................... 8digox..................................... 8digoxin.................................. 8DILANTIN............................. 4DILATRATE-SR....................8diltiazem hcl.......................... 8diltiazem hcl er......................8

diltiazem hcl er beads........... 8diltiazem hcl er coated beads.................................... 8DILTIAZEM HCL-DEXTROSE.......................... 8DILTIAZEM HCL-SODIUM CHLORIDE........................... 8dilt-xr..................................... 8dipyridamole......................... 6DIURIL.................................. 9divalproex sodium.................4divalproex sodium er.............4DIVIGEL..............................13dofetilide............................... 9dotti ..................................... 13DOVATO...............................7doxazosin mesylate.............. 9drospiren-eth estrad-levomefol............................ 13drospirenone-ethinyl estradiol.............................. 13DUAVEE............................. 13DUETACT...........................11duloxetine hcl........................5DYRENIUM...........................9EDARBI................................ 9EDARBYCLOR..................... 9EDECRIN..............................9EDURANT............................ 7efavirenz............................... 7efavirenz-emtricitab-tenofovir................................ 7efavirenz-lamivudine-tenofovir................................ 7EFFIENT...............................6ELESTRIN.......................... 13elinest................................. 13ELIQUIS................................4ELIQUIS DVT/PE STARTER PACK.................. 4ELIXOPHYLLIN.................. 17ELLA................................... 13eluryng................................ 13emoquette...........................13emtricitabine......................... 7emtricitabine-tenofovir df...... 7EMTRIVA..............................7enalapril maleate.................. 9enalaprilat............................. 9enalapril-hydrochlorothiazide...............9enoxaparin sodium............... 4enpresse-28........................13

19

enskyce...............................13ENVARSUS XR.................. 16EPIDIOLEX...........................4epitol..................................... 4EPIVIR.................................. 7eplerenone............................9EPZICOM............................. 7EQUETRO............................ 7errin.....................................14escitalopram oxalate.............5esmolol hcl............................9ESMOLOL HCL.................... 9esmolol hcl-sodium chloride................................. 9estarylla.............................. 14estradiol.............................. 14estradiol valerate................ 14estradiol-norethindrone acet..................................... 14ESTROGEL........................ 14ESTROSTEP FE................ 14ethacrynate sodium.............. 9ethacrynic acid......................9ethosuximide.........................4ethynodiol diac-eth estradiol.............................. 14etonogestrel-ethinyl estradiol.............................. 14EVAMIST............................ 14EVENITY............................ 16everolimus.......................... 16EVISTA............................... 13EVOTAZ............................... 7exemestane.......................... 5EZALLOR SPRINKLE...........9ezetimibe.............................. 9ezetimibe-simvastatin........... 9falmina................................ 14famotidine........................... 12FANAPT................................6FANAPT TITRATION PACK.................................... 6FARESTON.......................... 5FARXIGA............................ 11fayosim............................... 14felbamate.............................. 4FELBATOL........................... 4felodipine er.......................... 9FEMARA...............................5FEMHRT LOW DOSE........ 14femynor...............................14fenofibrate.............................9fenofibrate micronized.......... 9

fenofibric acid........................9FENOGLIDE......................... 9FETZIMA.............................. 5FIBRICOR.............................9flecainide acetate..................9FLOLIPID..............................9FLOVENT DISKUS.............17FLOVENT HFA................... 17fluoxetine hcl.........................5fluphenazine decanoate........6fluphenazine hcl....................6fluticasone-salmeterol.........17FLUTICASONE-SALMETEROL....................17fluvastatin sodium................. 9fluvastatin sodium er.............9fluvoxamine maleate.............5fluvoxamine maleate er.........5fondaparinux sodium............ 4FORTEO.............................16FOSAMAX.......................... 16fosamprenavir calcium..........7fosinopril sodium...................9fosinopril sodium-hctz........... 9fosphenytoin sodium.............4FRAGMIN............................. 4furosemide............................ 9FUROSEMIDE IN SODIUM CHLORIDE............9FUZEON............................... 7fyavolv.................................14FYCOMPA............................ 4gabapentin............................ 4GABITRIL............................. 4gavilyte-c.............................12gavilyte-g............................ 12gavilyte-h............................ 12gavilyte-n with flavor pack...12gemfibrozil ............................ 9gengraf................................16GENVOYA............................ 7GEODON..............................6gianvi.................................. 14glimepiride.......................... 11glipizide er...........................11glipizide ir............................11glipizide xl........................... 11glipizide-metformin hcl........ 11GLUCOTROL..................... 11GLUCOTROL XL................ 11glyburide............................. 11glyburide micronized...........11glyburide-metformin............ 11

GLYNASE...........................11GLYSET..............................11GLYXAMBI......................... 11GONITRO............................. 9guanfacine hcl.......................9hailey 1.5/30....................... 14hailey 24 fe......................... 14hailey fe 1.5/30................... 14hailey fe 1/20...................... 14HALDOL............................... 6HALDOL DECANOATE........ 6haloperidol............................ 6haloperidol decanoate.......... 6haloperidol lactate.................6heather................................14HELIDAC THERAPY.......... 12HEMANGEOL.......................9heparin (porcine) in nacl....... 4HEPARIN (PORCINE) IN NACL.................................... 4heparin lock flush................16heparin sod (porcine) in d5w....................................... 4heparin sodium (porcine)...... 4heparin sodium (porcine) pf...........................................4heparin sodium lock flush... 16HUMALOG KWIKPEN........ 12HUMALOG MIX 50/50 KWIKPEN........................... 12HUMALOG MIX 50/50 VIAL.................................... 12HUMALOG MIX 75/25 KWIKPEN........................... 12HUMALOG MIX 75/25 VIAL.................................... 12HUMALOG U-100 JUNIOR KWIKPEN........................... 12HUMALOG VIAL.................12HUMULIN 70/30 KWIKPEN........................... 12HUMULIN 70/30 VIAL.........12HUMULIN N KWIKPEN...... 12HUMULIN N VIAL............... 12HUMULIN R U-500 KWIKPEN........................... 12HUMULIN R U-500 VIAL.... 12HUMULIN R VIAL............... 12hydralazine hcl......................9hydrochlorothiazide...............9hydroxychloroquine sulfate... 6ibandronate sodium............ 16ibutilide fumarate.................. 9

20

IMURAN..............................16incassia...............................14indapamide........................... 9INSPRA................................ 9INTELENCE..........................7introvale.............................. 14INVEGA................................ 6INVEGA SUSTENNA............6INVEGA TRINZA.................. 6INVIRASE............................. 7ipratropium bromide............17ipratropium-albuterol...........17irbesartan..............................9irbesartan-hydrochlorothiazide...............9ISENTRESS......................... 7ISENTRESS HD................... 7isibloom...............................14isoproterenol hcl................... 9ISORDIL TITRADOSE..........9isosorbide dinitrate................9isosorbide mononitrate......... 9isosorbide mononitrate er..... 9isradipine.............................. 9ISUPREL.............................. 9jaimiess...............................14jantoven................................ 4JANUMET...........................11JANUMET XR.....................11JANUVIA.............................11JARDIANCE....................... 11jasmiel.................................14jencycla...............................14JENTADUETO....................11JENTADUETO XR..............11jinteli ....................................14jolessa.................................14juleber................................. 14JULUCA................................7junel 1.5/30......................... 14junel 1/20............................ 14junel fe 1.5/30..................... 14junel fe 1/20........................ 14junel fe 24........................... 14JUXTAPID............................ 9kaitlib fe...............................14KALETRA............................. 7kalliga..................................14kariva.................................. 14kelnor 1/35.......................... 14kelnor 1/50.......................... 14KENGREAL.......................... 6KRINTAFEL.......................... 6

kurvelo................................ 14KYLEENA........................... 14LABETALOL HCL................. 9labetalol hcl...........................9lamivudine.............................7lamivudine-zidovudine.......... 7lamotrigine............................ 4lamotrigine er........................ 4lamotrigine starter kit-blue.... 4lamotrigine starter kit-green.....................................4lamotrigine starter kit-orange...................................4LANOXIN.............................. 9LANOXIN PEDIATRIC..........9LANTUS SOLOSTAR......... 12LANTUS U-100 VIAL.......... 12larin 1.5/30.......................... 14larin 1/20............................. 14larin 24 fe............................ 14larin fe 1.5/30...................... 14larin fe 1/20......................... 14larissia.................................14LATUDA................................6layolis fe..............................14leena................................... 14lessina.................................14letrozole................................ 5levalbuterol hcl....................17LEVEMIR U-100 FLEXTOUCH...................... 12LEVEMIR U-100 VIAL........ 12levetiracetam........................ 5levetiracetam er.................... 5levetiracetam in nacl............. 5levonest.............................. 14levonorgest-eth est & eth est....................................... 14levonorgest-eth estrad 91-day...................................... 14levonorgestrel-ethinyl estrad..................................14levonorg-eth estrad triphasic.............................. 14levora 0.15/30 (28)..............14LEXIVA................................. 7LILETTA (52 MG)............... 14lillow.................................... 14LIPOFEN.............................. 9lisinopril .................................9lisinopril-hydrochlorothiazide...............9lojaimiess............................ 14

LONHALA MAGNAIR REFILL KIT......................... 17LONHALA MAGNAIR STARTER KIT.................... 17LOPID................................... 9lopinavir-ritonavir.................. 7LOPRESSOR....................... 9LOPRESSOR HCT............... 9loryna.................................. 14losartan potassium................9losartan potassium-hctz........9LOSEASONIQUE............... 14LOTENSIN............................9LOTENSIN HCT................... 9lovastatin...............................9LOVENOX............................ 4low-ogestrel........................ 14loxapine succinate................ 6lo-zumandimine.................. 14lutera...................................14LYUMJEV........................... 12LYUMJEV KWIKPEN..........12lyza..................................... 14MALARONE..........................6maprotiline hcl.......................5marlissa.............................. 14matzim la.............................. 9MAXZIDE..............................9MAXZIDE-25.........................9medroxyprogesterone acetate................................ 14mefloquine hcl.......................6melodetta 24 fe................... 14MENEST.............................14MENOSTAR....................... 14metaproterenol sulfate........ 17metformin hcl er.................. 11metformin hcl ir ................... 11methyldopa......................... 10methyldopa-hydrochlorothiazide.............10metolazone......................... 10metoprolol succinate er.......10metoprolol tartrate...............10metoprolol-hydrochlorothiazide.............10metyrosine.......................... 10MIACALCIN........................ 16mibelas 24 fe...................... 14microgestin 1.5/30.............. 14microgestin 1/20................. 14microgestin fe 1.5/30.......... 14microgestin fe 1/20............. 14

21

miglitol.................................11mili ...................................... 15milrinone lactate..................10milrinone lactate in dextrose.............................. 10mimvey............................... 15MINIPRESS........................ 10minitran............................... 10MINIVELLE......................... 15minoxidil ..............................10MIRCETTE......................... 15MIRENA (52 MG)................15misoprostol......................... 12moexipril hcl........................10molindone hcl........................6mono-linyah........................ 15montelukast sodium............17MULTAQ.............................10mycophenolate mofetil ........16mycophenolate mofetil hcl.. 16mycophenolate sodium.......16MYFORTIC......................... 16MYSOLINE........................... 5MYXREDLIN.......................12nadolol................................ 10NATAZIA.............................15nateglinide.......................... 11NATPARA...........................16necon 0.5/35 (28)................15nefazodone hcl..................... 5NEMBUTAL.......................... 5NEORAL............................. 16nevirapine............................. 7nevirapine er......................... 7NEXLETOL......................... 10NEXLIZET...........................10NEXTERONE..................... 10niacin er (antihyperlipidemic).............10nicardipine hcl.....................10NICARDIPINE HCL IN NACL.................................. 10NICOTROL........................... 4NICOTROL NS..................... 4nifedipine............................ 10nifedipine er........................ 10nifedipine er osmotic release................................ 10nikki.....................................15nimodipine.......................... 10nisoldipine er.......................10NITRO-BID......................... 10NITRO-DUR........................10

nitroglycerin........................ 10nitroglycerin in d5w............. 10NITROLINGUAL................. 10NITROMIST........................ 10NITROPRESS.................... 10nitroprusside sodium...........10NITRO-TIME.......................10nizatidine.............................12nora-be............................... 15norethin ace-eth estrad-fe...15norethindrone......................15norethindrone acet-ethinyl est....................................... 15norethindrone-eth estradiol.15norethin-eth estradiol-fe......15norgestimate-eth estradiol.. 15norgestimate-ethinyl estradiol triphasic................15norlyda................................ 15norlyroc............................... 15nortrel 0.5/35 (28)............... 15nortrel 1/35 (21).................. 15nortrel 1/35 (28).................. 15nortrel 7/7/7.........................15NORVIR................................7NUPLAZID............................ 6NUVARING.........................15NYMALIZE..........................10ocella.................................. 15ODEFSEY.............................7olanzapine............................ 6olanzapine-fluoxetine hcl...... 5olmesartan medoxomil........10olmesartan medoxomil-hctz..................................... 10olmesartan-amlodipine-hctz..................................... 10OMECLAMOX-PAK............ 12ORIAHNN........................... 15orsythia............................... 15OSPHENA.......................... 13oxcarbazepine...................... 5OZEMPIC........................... 11PACERONE........................10pacerone.............................10paliperidone er...................... 6pamidronate disodium........ 16PARAGARD INTRAUTERINE COPPER. 15paroxetine hcl....................... 5paroxetine hcl er................... 5PAXIL....................................5

peg 3350-kcl-na bicarb-nacl..................................... 12peg-3350/electrolytes......... 12peg-3350/electrolytes/ascorbat..12PEGANONE......................... 5peg-kcl-nacl-nasulf-na asc-c.......................................... 12peg-prep............................. 12pentazocine-naloxone hcl..... 4pentobarbital sodium............ 5PERFOROMIST................. 17perindopril erbumine........... 10perphenazine........................ 5PERSERIS............................6phenobarbital........................ 5phenobarbital sodium........... 5phenoxybenzamine hcl....... 10phentolamine mesylate.......10PHENYTEK.......................... 5phenytoin.............................. 5phenytoin infatabs.................5phenytoin sodium..................5phenytoin sodium extended............................... 5philith.................................. 15PIFELTRO............................ 7pimtrea................................15pindolol............................... 10pioglitazone hcl................... 11pioglitazone hcl-glimepiride 11pioglitazone hcl-metformin hcl....................................... 11pirmella 1/35....................... 15pirmella 7/7/7...................... 15portia-28..............................15PRADAXA.............................4PRALUENT.........................10prasugrel hcl......................... 6pravastatin sodium..............10prazosin hcl.........................10PRECOSE.......................... 12PREFEST........................... 15pregabalin........................... 11PREMARIN.........................15PREMPHASE..................... 15PREMPRO..........................15PRESTALIA........................ 10prevalite.............................. 10previfem.............................. 15PREZCOBIX......................... 7PREZISTA............................ 7primaquine phosphate.......... 6

22

primidone.............................. 5PROBUPHINE IMPLANT KIT........................................ 4PROCARDIA...................... 10PROCARDIA XL................. 10prochlorperazine................... 5prochlorperazine edisylate....5prochlorperazine maleate..... 5PROGRAF.......................... 16propafenone hcl.................. 10propafenone hcl er..............10propranolol hcl.................... 10propranolol hcl er................ 10propranolol-hctz.................. 10PULMICORT FLEXHALER.17PYLERA..............................12pyrimethamine...................... 6QUALAQUIN.........................6QUARTETTE...................... 15quetiapine fumarate.............. 6quetiapine fumarate er..........6quinapril hcl.........................10quinapril-hydrochlorothiazide.............10quinine sulfate.......................6raloxifene hcl.......................13ramipril ................................ 10ranolazine er....................... 10RAPAMUNE....................... 16RECLAST........................... 16reclipsen............................. 15repaglinide.......................... 12REPATHA...........................10REPATHA PUSHTRONEX SYSTEM............................. 10REPATHA SURECLICK..... 10RETROVIR........................... 7REXULTI...............................6REYATAZ............................. 7RIOMET..............................12RIOMET ER........................12risedronate sodium............. 16RISPERDAL CONSTA......... 6risperidone............................ 6ritonavir................................. 7rivelsa................................. 15rosuvastatin calcium........... 10roweepra...............................5roweepra xr...........................5rufinamide............................. 5RUKOBIA..............................7RYBELSUS.........................12RYTHMOL SR.................... 10

SANDIMMUNE................... 16SAPHRIS.............................. 6SAVAYSA............................. 4SELZENTRY.........................7SEREVENT DISKUS.......... 17sertraline hcl......................... 5setlakin................................15sharobel.............................. 15simliya.................................15simpesse.............................15simvastatin..........................10sirolimus..............................16SKYLA................................ 15SODIUM DIURIL.................10SODIUM EDECRIN............ 10sodium nitroprusside...........10SOLIQUA............................12SOLTAMOX..........................5sorine.................................. 10SOTALOL HCL................... 10sotalol hcl............................10sotalol hcl (af)..................... 10SOTYLIZE.......................... 10SPIRIVA HANDIHALER..... 17SPIRIVA RESPIMAT.......... 17spironolactone.................... 11spironolactone-hctz.............11sprintec 28.......................... 15sronyx................................. 15STARLIX.............................12stavudine.............................. 7STIOLTO RESPIMAT......... 17STRIBILD..............................7STRIVERDI RESPIMAT..... 17SUBLOCADE........................4subvenite.............................. 5subvenite starter kit-blue.......5subvenite starter kit-green.... 5subvenite starter kit-orange.. 5sucralfate............................ 12SULAR................................11SUPREP BOWEL PREP KIT...................................... 12SUSTIVA.............................. 7syeda.................................. 15SYMBICORT...................... 17SYMBYAX............................ 5SYMFI...................................7SYMFI LO............................. 7SYMLINPEN 120................ 12SYMLINPEN 60.................. 12SYMPAZAN.......................... 5SYMTUZA.............................7

SYNJARDY.........................12SYNJARDY XR...................12tacrolimus........................... 16TALICIA.............................. 12tamoxifen citrate................... 5tarina 24 fe..........................15tarina fe 1/20.......................15tarina fe 1/20 eq..................15TARKA................................11taztia xt............................... 11TEKTURNA........................ 11TEKTURNA HCT................ 11telmisartan.......................... 11telmisartan-amlodipine........11telmisartan-hctz.................. 11tenofovir disoproxil fumarate................................7TENORETIC 100................ 11TENORETIC 50.................. 11terazosin hcl........................13terbutaline sulfate............... 17TERIPARATIDE (RECOMBINANT)...............16THEO-24.............................17theophylline.........................17theophylline er.................... 17theophylline in d5w............. 17thioridazine hcl......................6thiothixene............................ 6tiadylt er.............................. 11tiagabine hcl..........................5TIAZAC............................... 11tilia fe.................................. 15timolol maleate....................11TIVICAY................................7TIVICAY PD..........................7tolbutamide......................... 12topiramate.............................5toremifene citrate.................. 5torsemide............................ 11TOUJEO MAX SOLOSTAR........................ 12TOUJEO SOLOSTAR.........12TRADJENTA.......................12trandolapril .......................... 11trandolapril-verapamil hcl er.........................................11trazodone hcl........................ 5TRELEGY ELLIPTA............17tri femynor...........................15triamterene..........................11triamterene-hctz..................11tri-estarylla.......................... 15

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trifluoperazine hcl..................6TRIJARDY XR.................... 12tri-legest fe.......................... 15tri-linyah.............................. 15TRILIPIX............................. 11tri-lo-estarylla...................... 15tri-lo-marzia.........................15tri-lo-mili .............................. 15tri-lo-sprintec....................... 15trilyte................................... 13tri-mili .................................. 15TRINTELLIX......................... 5tri-previfem..........................15tri-sprintec........................... 15TRIUMEQ............................. 7trivora (28).......................... 15tri-vylibra............................. 15tri-vylibra lo......................... 15TRIZIVIR...............................7TROGARZO......................... 7TRULICITY......................... 12tulana.................................. 15TWIRLA.............................. 15TWYNSTA.......................... 11tyblume............................... 15TYBOST............................... 7tydemy................................ 15TYMLOS............................. 16valproate sodium.................. 5valproic acid..........................5valsartan............................. 11valsartan-hydrochlorothiazide.............11VASERETIC....................... 11VASOTEC...........................11VECAMYL...........................11velivet..................................15venlafaxine hcl...................... 5venlafaxine hcl er..................5verapamil hcl.......................11verapamil hcl er.................. 11VERELAN........................... 11VERELAN PM.....................11VERSACLOZ........................ 6VICTOZA............................ 12vienva................................. 15vigabatrin.............................. 5vigadrone.............................. 5VIIBRYD............................... 5VIIBRYD STARTER PACK...5VIMPAT................................ 5viorele................................. 15VIRACEPT............................7

VIRAMUNE...........................7VIRAMUNE XR.....................7VIREAD................................ 7volnea................................. 15VRAYLAR............................. 6vyfemla............................... 16vylibra................................. 16warfarin sodium.................... 4wera.................................... 16wixela inhub........................ 17wymzya fe...........................16XARELTO............................. 4XARELTO STARTER PACK.................................... 4XIGDUO XR........................12XOPENEX.......................... 17XOPENEX CONCENTRATE................ 17xulane................................. 16XULTOPHY........................ 12YUPELRI............................ 17zafirlukast............................17zarah...................................16ZARONTIN........................... 5ZESTORETIC..................... 11ZIAC....................................11ZIAGEN................................ 7zidovudine.............................7zileuton er........................... 17ziprasidone hcl......................6ziprasidone mesylate............ 6zoledronic acid....................16zonisamide............................5ZONTIVITY........................... 6ZORTRESS........................ 16zovia 1/35e (28).................. 16ZUBSOLV............................. 4zumandimine...................... 16ZYPREXA RELPREVV.........6ZYPREXA ZYDIS................. 6

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This list is should be used as a reference and may not include all medications. Brand or generic availability may not be current because of market changes. Using generics may be required based on your plan benefit.

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