5-tier/open formulary plan...2016/01/01 · of our 2016 preferred drug guide. this guide provides...

© 2016, Magellan Health Services, Inc. All Rights Reserved. Updated 1.1.16

2016 Preferred Drug Guide 5-Tier/Open Formulary Plan

Magellan Pharmacy Solutions Preferred Drug List (2016) 2

© 2016, Magellan Health Services, Inc. All Rights Reserved.

Table of Contents Table of Contents ..................................................................................................................................................................... 2

Introduction ............................................................................................................................................................................... 3

Pharmacy Benefit Programs ............................................................................................................................................... 4

ANALGESICS/PAIN MANAGEMENT ............................................................................................................................ 9

NSAIDS .................................................................................................................................................................................. 12

ANTI-INFECTIVE AGENTS ............................................................................................................................................ 13

ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS......................................................................................... 19

CARDIOVASCULAR MEDICATIONS ........................................................................................................................... 23

CENTRAL NERVOUS SYSTEM ...................................................................................................................................... 30

DERMATOLOGIC MEDICATIONS ................................................................................................................................ 38

EAR-NOSE MEDICATIONS ............................................................................................................................................. 41

ENDOCRINE MEDICATIONS ......................................................................................................................................... 42

GASTROINTESTINAL MEDICATIONS ....................................................................................................................... 47

IMMUNOLOGICALS .......................................................................................................................................................... 50

BLOOD MODIFIERS .......................................................................................................................................................... 50

OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS ..................................................................................... 52

OPHTHALMIC MEDICATIONS ..................................................................................................................................... 57

RESPIRATORY MEDICATIONS .................................................................................................................................... 60

UROLOGICAL MEDICATIONS ....................................................................................................................................... 62

Index ........................................................................................................................................................................................... 64



Introduction To help you know how drugs are covered by your plan, we are pleased to provide you with a copy

of our 2016 Preferred Drug Guide. This guide provides helpful information on the Magellan

Pharmacy Solutions Drug List and your pharmacy benefit plan. You may want to take this guide

with you when you see your doctor to talk about what is covered under your plan.

Many commonly prescribed drugs are listed in this guide. Please remember this is not a complete

list of drugs covered under your plan. Because thousands of drugs are included in your pharmacy

benefits plan, we only list the most commonly prescribed ones. It represents an abbreviated version

of the drug list (formulary) that is at the core of your prescription-drug benefit plan. The list is not

all inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to

ask your doctor to prescribe generic drugs whenever appropriate.

Note: The decision concerning whether a prescription medication should be prescribed must be

made by you and your physician. Any and all decisions that require or pertain to

independent professional medical judgments or training or the need for and dosage of a

prescription medication must be made solely by you and your treating physician in

accordance with the patient/physician relationship.



Pharmacy Benefit Programs You are enrolled in a five-tier/open formulary plan. Five-tier means your plan has five different co-

pay (or co-insurance) levels that you pay out of pocket for your covered prescription drugs.

Open formulary means your plan covers most prescription drugs. Your plan may not cover certain

drugs, even though some are listed, such as contraceptives, infertility drugs, erectile dysfunction

drugs, and diabetic supplies. Please see your plan documents for a complete description of your

pharmacy benefit or call Member Services at the toll-free number on your member ID card.

Co-pay/Co-insurance Tier Type of Drug

Tier 1 Covered generic drugs

Tier 2 Covered preferred brand-name drugs

Tier 3 Covered specialty preferred drugs

Tier 4 Covered non-preferred generic or brand-name drugs

Tier 5 Covered specialty non-preferred drugs

Preferred Drug List

The Preferred Drug List (formulary) is meant to give you a general view of drugs covered by your

plan. Changes to the list are based on the latest medical findings as well as information from the

Food and Drug Administration (FDA) and drug makers.

This list includes both brand-name and generic drugs and is updated regularly. Your Health Plan

will generally cover the drugs listed on our Preferred Drug List as long as they are medically

necessary and plan rules are followed. Coverage is not limited to drugs on the Preferred Drug List.

Your plan has different co-pay or co-insurance tiers for generic, brand-name, preferred, and non-

preferred drugs. Usually, preferred drugs are covered at a lower co-pay or co-insurance tier, which

means you pay less out of pocket for those drugs.

The Preferred Drug List is subject to change. We choose drugs for this list based on reliable medical

data, safety, and cost. Many drugs, including drugs on the Preferred Drug List, are subject to rebate

arrangements between Magellan Pharmacy Solutions and the manufacturer of those drugs.

When you talk to your doctor about what drug may be right for you, it is important to remember

that you and your doctor are responsible for making the final decision on your drug therapy.

Review of the Preferred Drug List

Magellan Pharmacy Solutions’ Pharmaceutical and Therapeutics (P&T) Committee reviews

available clinical literature for drugs that have been approved by the FDA. The primary purpose of

the Committee is to assist in developing and monitoring the Preferred Drug List, and to establish

programs and procedures that promote the appropriate and cost-effective use of medications.



Preferred Drug List Development

Magellan Pharmacy Solutions’ P&T Committee meets regularly to review new drugs and new

information about drugs that are already on the market. The Committee reviews available

information concerning safety, effectiveness, and current use in therapy. The P&T Committee

reviews the scientific evidence from American Hospital Formulary Service Drug Information

(AHFS-DI), IPD, Micromedex, and other databases, including relevant findings of federal

government agencies, pharmaceutical manufacturers, medical professional associations, national

commissions, and peer-reviewed journals.

Our P&T Committee includes licensed pharmacists and doctors, including those who are currently

in practice and others who are Magellan Pharmacy Solutions’ employees. All committee members

must tell us if they are in a situation that can create a conflict of interest or if they have a financial

stake that might affect their decisions.

Once the P&T Committee completes its clinical review, we also consider overall value (including

cost and manufacturer rebate arrangements) and other factors before adding or removing a drug

from the Preferred Drug List.

Prior Authorization

Prior Authorization* encourages the appropriate and cost-effective use of drugs by allowing

coverage only when certain conditions are met.

For example, prior authorization promotes compliance with dosing guidelines. It also helps health

care providers avoid inappropriate duplicate therapies as well as check that a drug is being used

based on generally accepted medical criteria. The prior authorization program is based upon

current medical findings, FDA-approved manufacturer labeling information, and cost and

manufacturer rebate arrangements.

If your plan requires prior authorization, the following applies:

Your doctor or the person you appoint to manage your care must contact Magellan

Pharmacy Solutions to request approval for coverage of the prior authorized drug. If we

approve the request, we will notify you or your doctor. The drug will then be covered at the

applicable co-payment or co-insurance under your plan. You will also be notified of

approvals where the state requires notification to members.

If the request is denied, you and your doctor will be notified. You can still purchase the drug

for the full price.

For information on whether prior authorization applies to your plan, please refer to your plan

documents or call Member Services at the toll-free number on your member ID card.

* The prior authorization list is subject to change.



Quantity Limits

Your plan may limit the amount of a drug you can receive at one time. These limits help your doctor

and pharmacist check that the drugs are used appropriately while promoting patient safety. We use

medical guidelines, FDA approval, and guidance from drug makers to set these coverage limits. The

Quantity Limits program includes:

Dose Optimization Edits – Limits coverage of prescriptions to one dose per day for drugs

that are approved for once or twice-daily dosing

Maximum Daily Dose – A message is sent to the pharmacy if a prescription is higher than

the maximum allowed dose

Quantity Limits Over Time – Limits coverage of prescriptions to a specific number of units

in a defined amount of time

Step-Therapy

With step-therapy, you must try one or more prerequisite drugs before your plan will cover a step-

therapy drug. Prerequisite drugs are FDA-approved, treat the same condition(s), and they may also

be available to you at a lower co-pay or co-insurance tier.

If it is medically necessary for you to use a drug on the step-therapy list, your doctor or the person

you appoint to manage your care may request a medical exception. If the request is approved, we

will notify you or your doctor. The drug will then be covered at the applicable co-payment or co-

insurance under your plan. You will also be notified of approvals where states require it. If the

request is denied, we will notify you and your doctor.

For information on whether step-therapy applies to your plan, please refer to your plan documents.

You may also call Member Services at the toll-free number on your member ID card.

Therapeutic Duplication

Therapeutic duplication is a potentially dangerous situation that occurs when two similar drugs are

prescribed at the same time. Rarely are two drugs from the same category necessary to treat a

medical condition.

Therapeutic duplication can occur when two different doctors are prescribing drugs for the same

patient. This can also happen when a doctor changes a patient’s prescription from one drug to

another within the same therapeutic class but does not discontinue the first drug. In either

situation, the patient may end up taking two drugs with similar actions, potentially leading to

serious side effects.

If therapeutic duplication is identified by our claims system, the member’s pharmacist may ask the

member and his or her doctor whether he or she should be taking both drugs. The physician can

then help determine if both drugs are necessary, or whether one of the drugs should be

discontinued.



Generic Drugs

Drug manufacturers develop and release new drugs under a brand name. When the patent expires,

other manufacturers are then able to make duplicate versions of the same drug. Generic drugs are

chemically the same as their branded counterparts. They are also the same in dosage, safety,

strength, form, and intended use. In addition, generics usually cost less than brand-name drugs.

Generic drugs are only available after the FDA approves them. When filling your prescription, your

pharmacist generally can substitute a generic drug for a brand-name drug when the generic is rated

by the FDA as equivalent and also where it is permitted by your doctor and state law.

Medications That are Not Covered

Your pharmacy benefit may not cover select medications. The following are some of the reasons a

medication may not be covered:

The medication has been shown to have excessive adverse effects and/or safer alternatives.

The medication has a preferred formulary alternative or over-the-counter (OTC)

alternative.

The medication is no longer marketed.

The medication has a widely available/distributed A-rated generic equivalent formulation.

The medication has been repackaged. This is a pharmaceutical product that is removed

from the original manufacturer container (Brand Originator) and repackaged by another

manufacturer with a different National Drug Code (NDC).

DESI drugs Drug Efficacy Study and Implementation (DESI) drug products and known

related drug products are defined as less than effective by the Food and Drug

Administration, because there is a lack of substantial evidence of effectiveness for all

labeling indications and because a compelling justification for their medical need has not

been established.

Compounded or Bulk Products

Compound prescriptions require a prior authorization (PA) when a claim is $400.00 or more

Note: Check your benefit booklet, certificate of coverage, contract, member handbook, or

prescription drug endorsement to determine the medication exclusions that apply to your

plan.



Specialty Pharmacy Medications

Specialty pharmacy medications are high-cost drugs, including but not limited to oral, topical,

inhaled, inserted or implanted, and injected routes of administration without regard to setting.

They may require close supervision and monitoring of the patient’s therapy, or used to treat and

diagnose rare or complex diseases, or require special handling, or are biologic/biosimilar drugs, or

may have limited access or distribution.

For Specialty drug prior authorization:

Your doctor must call or fax Magellan Customer Service for prior authorization before

submitting your prescription:

Phone: 1-800-651-8921

Fax: 1-888-272-1349

For Specialty drug distribution:

Your doctor must call Shands Medical Plaza Pharmacy+

2000 SW Archer Road

Phone: 1-888-345-8270 or 1-352-265-8270

Open: M-F 8:30 a.m. – 5 p.m.

Or, call MRx Specialty Pharmacy

Phone: 1-866-554-2673

Fax: 1-866-364-2673

Customer Service M-F 8 a.m. – 7 p.m. EST. On Call Pharmacists 24/7 for Urgent Requests.

Note: Check your benefit booklet, certificate of coverage, contract, member handbook, or

prescription drug endorsement for information on how specialty pharmacy medications are

covered on your plan.

Therapeutic Class List Key

UPPERCASE Brand-name medication

lower case Generic medication

FE Formulary-excluded medication

NC Not covered

PA Prior authorization required under most plans

ST Step-therapy applies under most plans

QL Quantity limit applies under most plans

SP Specialty medication available from Shands Medical Plaza Pharmacy+ or ICORE pharmacy

(+Shands UF employees and dependents will exclusively use Shands Pharmacies for specialty medications.

All other GatorCare members will have a choice of pharmacies listed above)

SPN Specialty medications may not be available through Shands Medical Plaza Pharmacy or ICORE pharmacy

MED Injectable medication that may be covered under the medical benefit

* Drug is subject to non-preferred status when a generic is available throughout the year

1, 2, 3, 4, 5 The numbers found in the drug lists represent co-pay tiers



Trade Name Co-pay Tier

PA ST QL COMMENTS

ANALGESICS/PAIN MANAGEMENT

Anti-Gout Agents

allopurinol tablet 1

COLCRYS TABLET 2

MITIGARE 4 PA QL 2/day

probenecid/Colchicine tablet 1

probenecid tablet 1

ULORIC TABLET 2

Anti-Migraine Agents/

AXERT FE PA QL 8 tablets/30 days

dihydroergotamine mesylate, nasal 1

ergotamine-caffeine 1

FROVA FE PA QL 12 tablets/30 days

IMITREX, nasal, inj 4 PA QL 18 x 25mg; 18 x 50 mg; 9 x 100 mg tablets/30 days ; 16 x 5 mg; 8 x 20 mg single use units/30 days ; 4 inj/30 days

MAXALT*, MLT* 4 PA QL 12 tablets/30 days

MIGRANAL 4 Preferred Alternative: dihydroergotamine nasal

naratriptan tablet 1 QL 8/30 days

RELPAX 2 QL 6/30 days

rizatriptan Tablet, ODT 1 QL 12/30 days

sumatriptan nasal spray 1

QL 5mg – 16 units/30 days ; 20mg – 8 units/30

days

sumatriptan tablet, cartridge, syringe, vial 1

QL injection – 4/30 days ; tablets – 25mg, 50mg

18/30 days ; 100mg 9/30 days

SUMAVEL DOSEPRO 2 QL 4/30 days

TREXIMET 4

QL 9/30 days; formulary alternative: naproxen,

naproxen sodium, sumatriptan succinate

ZOLMITRIPAN, ODT 1 QL 8/30 days

ZOMIG* TABLET, ZMT TABLET* 4

QL 8/30 days; formulary alternative: sumatriptan

succinate

ZOMIG NASAL SPRAY 2 QL 8/30 days

DMARDs/Biologics

ACTEMRA 3 SP




PA ST QL COMMENTS

CIMZIA FE SP; Covered preferred alternatives: Enbrel,

Humira,

COSENTYX 3 PA SP

ENBREL KIT, SYRINGE, SURECLICK 3 PA SP

ENTYVIO MED

HUMIRA KIT, PEN, SYRINGE, PEDIATRIC 3 PA SP

KINERET 5 PA SP

leflunomide tablet 1

methotrexate tablet 1

ORENCIA SYRINGE 3 PA SP

OTEZLA 3 PA SP

RASUVO 3 PA QL SP; 4 autoinjectors/month

SIMPONI 50MG/0.5ML ARIA FE PA SP;

SIMPONI 100MG/ML 3 PA SP

STELARA 3 PA Preferred alternatives: Enbrel, Humira,

XELJANZ FE PA

QL SP, 2 tabs/day Covered preferred alternatives:

Enbrel, Humira

Gold Compounds

RIDAURA CAPSULE 2

Analgesics, Narcotics

ABSTRAL FE

AVINZA FE QL 1/day: Covered Alternatives: morphine sulfate ER, oxymorphone ER, Nucynta ER, Opana ER

acetaminophen/codeine tablet, solution 1

acetaminophen/butalbital/caffeine/codeine

tablet 1

aspirin/butalbital/caffeine/codeine capsule 1

aspirin/codeine tablet 1

buprenorphine sublingual tab, syringe, vial 1 PA QL Tab: 3/day

butorphanol spray, syringe, vial 1

BUTRANS 2 QL 0.15/day (4 patches/month)

codeine tablet 1

CONZIP 4 QL 2/day

DURAGESIC PATCH 4 QL 0.15/day (15 patches/30 days)




PA ST QL COMMENTS

EMBEDA ER 4 QL 2/day

EXALGO FE QL 1day: Covered Alternatives: morphine sulfate ER, oxymorphone ER, Nucynta ER, Opana ER

fentanyl patch 1 QL 0.15/day (15 patches/30 days)

FENTORA FE

hydrocodone/acetaminophen tablet 1

hydrocodone/ibuprofen tablet 1

hydromorphone solution, tablet, syringe, vial 1

HYSINGLA ER FE

KADIAN FE QL 2/day: Covered Alternatives: morphine sulfate ER, oxymorphone ER, Nucynta ER, Opana ER

LAZANDA 2

levorphanol 2mg tablet 1

methadone 10mg/5ml solution, solutab,

tablet

1

morphine solution 1

Morphine Sulfate Extended Release 1 QL 3/day

MS CONTIN 4 QL 3/day: Alternative: morphine sulfate ER

NUCYNTA, ER 2 QL ER (2/day)

ONSOLIS FE

OPANA ER* TABLET 2 QL 2/day

oxycodone/acetaminophen tablet 1

oxycodone capsule, solution, tablet, 1

oxycodone ER FE QL

OXYCONTIN* TABLET 2 PA QL 2/day

oxymorphone tablet, ER 1 QL 2/day (generic for Nucynta ER)

reprexain tablet 1

SUBSYS FE

tramadol tablet, ER 1 QL ER: 2/day

tramadol/acetaminophen tablet 1

trezix capsule 1

ULTRAM ER 4 QL 2/day

XARTEMIS XR 4 PA QL 120/month

ZOHYDRO ER FE




PA ST QL COMMENTS

Neuropathic Pain/Fibromyalgia

gabapentin capsule, solution, tablet 1

GRALISE 2

lidocaine cream, ointment FE

lidocaine 5% patch 1

LIDODERM 5% PATCH 4

LYRICA CAPSULE, SOLUTION 4

SAVELLA 2

NSAIDS

CELEBREX CAPSULE 4 QL 2/day

celecoxib 1 QL 2/day

diclofenac sodium tablet, enteric 1

diclofenac sodium drops (topical) 1

diclofenac/misoprostol tablet 1

DUEXIS FE

etodolac capsule, tablet, tablet ER 1

fenoprofen tablet 1

FLECTOR PATCH* 4 Preferred Alternatives: Meloxicam, Naproxen,

Voltaren Gel

flurbiprofen tablet 1

ibuprofen tablet FE all plain (and all formulations)

indomethacin capsule, ER 1

ketoprofen capsule, ER 1

ketorolac tablet 1

meclofenamate capsule 1

mefenamic acid capsule 1

meloxicam tablet 1

nabumetone tablet 1

naproxen tablet, suspension 1

oxaprozin caplet, tablet 1

PENNSAID 4 PA Generic alternative: diclofenac sodium drops

(topical)

piroxicam capsule 1




PA ST QL COMMENTS

sulindac tablet 1

tolmetin capsule, tablet 1

VIMOVO FE

VOLTAREN GEL 2

Skeletal Muscle Relaxants

baclofen tablet 1

chlorzoxazone tablet 1

cyclobenzaprine, tablet 1

dantrolene capsule 1

metaxalone tablet 1

methocarbamol tablet 1

orphenadrine tablet, ER 1

tizanidine capsule, tablet 1

ANTI-INFECTIVE AGENTS

Antibiotics – Aminoglycosides

Bethkis 3 PA QL SP: 2 vials per day (56 vials per 56 days)

Kitabis Pak FE QL SP: 2 vials per day (56 vials per 56 days)

TOBI

5 PA QL SP: Formulary alternative: tobramycin

inhalation solution; 2 vials per day (56 vials

per 56 days)

TOBI PODHALER 3 PA QL SP: 8 capsules per day (224 capsules per 56

days)

Tobramycin inhalation solution 3 PA QL SP: 2 vials per day (56 vials per 56 days)

Antibiotics – Cephalosporins

cefaclor suspension, capsule, ER 1

cefadroxil suspension, tablet 1

cefdinir capsule, suspension 1

cefditoren pivoxil tablet 1

cefpodoxime suspension, tablet 1

cefprozil suspension, tablet 1

cefuroxime tablet 1

cephalexin capsule, suspension 1




PA ST QL COMMENTS

Antibiotics – Fluoroquinolones

AVELOX* TAB, ABC pack 2

CIPRO TABLET 4

CIPRO ER 4

ciprofloxacin tablet 1

ciprofloxacin ER 1

CIPRO 5% SUSPENSION 2

FACTIVE 4 PA

LEVAQUIN 4 PA

levofloxacin tablet, solution 1

NOROXIN 4 PA

ofloxacin tablet 1

Antibiotics – Macrolides

azithromycin powder packet, suspension,

tablet

1

clarithromycin suspension, tablet, ER 1

EES GRANULES, FILMTAB 4 Preferred Alternative: azithromycin for

suspension

ERYPED SUSPENSION 4 Preferred Alternative: azithromycin for

suspension

ERY-TAB 250MG, 333MG EC TABLET 2

ERY-TAB 500 MG TABLET 4 Preferred Alternatives: erythromycin base,

erythromycin filmtab

erythrocin filmtab 1

erythromycin capsule, tablet, ec tablet,

suspension, granules

1

erythromycin/sulfisoxazole suspension 1

Antibiotics – Penicillins

amoxicillin chewable, capsule, suspension,

tablet

1

amoxicillin/clavulanate chewable,

suspension, tablet

1

ampicillin capsule, suspension 1

AUGMENTIN SUSPENSION 2




PA ST QL COMMENTS

dicloxacillin capsule 1

penicillin V potassium suspension, tablet 1

Antibiotics – Sulfonamides

smz-tmp ds 1

sulfadiazine tablet 1

sulfamethoxazole/trimethoprim ds tablet,

suspension

1

sulfasalazine tablet 1

sulfazine tablet, ec tablet 1

Antibiotics – Tetracyclines

avidoxy tablet 1

demeclocycline tablet 1

doxycycline capsule, tablet, suspension 1

minocycline, ER capsule 1

morgidox capsule 1

tetracycline capsule 1

Antifungals, Oral

clotrimazole troche 1

fluconazole suspension, tablet 1

flucytosine capsule 1

griseofulvin suspension 1

griseofulvin micro tablet 1

griseofulvin ultra tablet 1

itraconazole capsule 1

LAMISIL GRANULES 2

ketoconazole tablet 1

NOXAFIL SUSPENSION 2

nystain powder, suspension, tablet 1

SPORANOX SOLUTION 2

terbinafine tablet 1

VFEND SUSPENSION 4 Generic Alternative: voriconazole suspension

voriconazole suspension 1




PA ST QL COMMENTS

voriconazole tablet 1

GI Antibiotics

metronidazole tablet 1

neomycin 500mg tablet 1

vancomycin capsule 1

XIFAXAN TABLET 2

Antimalarials

atovaquone-proganil tablet 1

chloroquine tablet 1

COARTEM TABLET 2

DARAPRIM TABLET 2

hydroxychloroquine tablet 1

mefloquine tablet 1

PRIMAQUINE 2

quinine capsule 1

Anthelmintics

ALBENZA TABLET 2

ALINIA SUSPENSION, TABLET 2

mebendazole chew tablet 1

MEPRON 2

STROMECTOL TABLET 2

tinidazole 1

Antitubercular Agents

ethambutol tablet 1

isoniazid solution, tablet 1

MYCOBUTIN CAPSULE 2

PRIFTIN TABLET 2

pyrazinamide tablet 1

rifampin capsule 1

SIRTURO 2

Antivirals

acyclovir capsule, suspension, tablet 1




PA ST QL COMMENTS

amantadine 100mg capsule 1

famciclovir tablet 1

ganciclovir capsule 1

RELENZA DISKHALER 2

rimantadine tablet 1

TAMIFLU GELCAP, SUSPENSION 2

valacyclovir tablet 1

VALCYTE* SOLUTION 2

VALCYTE*TABLET 4

valganciclovir hcl 1

Antivirals, HIV/AIDS Therapy

abacavir/lamivudine/zidovudine 3 SP

abacavir tablet 3 SP

APTIVUS CAPSULE, SOLUTION 3 SP

ATRIPLA TABLET 3 SPN

CIDOFOVIR 3 SP

COMBIVIR 5 SP

COMPLERA 3 SP

CRIXIVAN CAPSULE 3 SP

didanosine capsule 3 SP

EDURANT TABLET 3 SP

EMTRIVA CAPSULE, SOLUTION 3 SPN

EPIVIR* SOLUTION 3 SP

Epivir , HBV (tablet only) 5 SP

EPZICOM TABLET 3 SPN

EVOTAZ 5 SP

FUZEON KIT, VIAL 3 SPN

HIVID TABLET 2

INTELENCE TABLET 3 SP

INVIRASE CAPSULE, TABLET 3 SP

ISENTRESS CHEWABLE, TABLET 3 SPN

KALETRA SOFTGEL, SOLUTION,TABLET 3 SP




PA ST QL COMMENTS

lamivudine tablet 3 SP

Lamivudine solution 3 SP

lamivudine/zidovudine tablet 3 SPN

LEXIVA SUSPENSION, TABLET 3 SP

nevirapine suspension, tablet 3 SP

NORVIR SOFTGEL CAPSULE, TABLET 3 SPN

PREZCOBIX 5 SP

PREZISTA TABLET 3 SPN

RESCRIPTOR TABLET 3 SP

REYATAZ CAPSULE 3 SPN

SELZENTRY TABLET 3 SP

stavudine capsule, solution 3 SP

STRIBILD TABLET 3 SP

SUSTIVA CAPSULE 3 SPN

TIVICAY 2 PA QL SP; 60/30 days

TRIZIVIR TABLET 5 SP

TRIUMEQ 3 SP

TRUVADA TABLET 3 SPN

VIDEX SOLUTION 3 SP

VIDEX EC 5 SP

VIRACEPT TABLET, POWDER 3 SP

VIRAMUNE, XR TABLET 5 SPN

VIREAD TABLET 3 SPN

VITEKTA 5 SP

ZERIT 5 SP

ZIAGEN SOLUTION 5 SPN

zidovudine capsule, syrup, tablet 3 SP

Nitrofuran Derivatives

nitrofurantoin capsule, suspension 1

nitrofurantoin macro capsule 1

nitrofurantion macro/monohydrate capsule 1




PA ST QL COMMENTS

ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS

Alkylating Agents, Oral

ALKERAN TABLET 2

cyclophosphamide tablet 1

CYCLOPHOSPHAMIDE CAPSULE 2

HEXALEN CAPSULE 3 PA QL SP, 390/30 days

HYCAMTIN 3 PA QL SP, 0.25mg: 23 cap/21 days,

1mg: 5 cap/21 days

hydroxyurea capsule 1

IMBRUVICA 3 PA SP

LEUKERAN TABLET 2

LOMUSTINE 2

MYLERAN TABLET 3 SP

TEMODAR CAPSULE 3 PA QL SP, 2500 mg/28days

Antiandrogenic Agents

bicalutamide tablet 1

flutamide capsule 1

NILANDRON TABLET 5 SP

XTANDI CAPSULE 3 PA QL SPN, 120/30days

ZYTIGA TABLET 3 PA QL SP, 120/30 days

Antimetabolites, Oral

Capcitabine 3 PA QL SP, 120/30days

mercaptopurine tablet 1

TABLOID TABLET 2

TREXALL TABLET 2

XELODA* TABLET 5 PA QL SP, 120/30days

Antineoplastics, Immunomodulators

POMALYST CAPSULE 3 PA QL SP, 21/28 days

REVLIMID CAPSULE 3 QL SP, 28 capsules/month

SYLATRON KIT; 4 PACK 3 PA SP

Antineoplastics, LHRH(GNRH) Agonist

leuprolide acetate 3 PA SP




PA ST QL COMMENTS

LUPRON DEPOT MED

LUPRON DEPOT PED MED

Antineoplastics, Miscellaneous

LYSODREN 3 SP

MESNEX 3 SP

SYNRIBO 3 SP

Tretinoin 10mg capsule 3 SP

Antineoplastics, Selective Retinoid X Receptor Agonist

TARGRETIN, ORAL 5 PA QL SP, 270 caps/month

TARGRETIN, TOPICAL 3 PA QL SP, 4 tubes/month

Antineoplastic Systemic Enzymes, Oral

ADEFOVIR DIPIVOXIL 3 SP

AFINITOR, DISPERZ 3 PA QL SP, 1/day

BOSULIF TABLET 3 PA QL SP, 100mg-4/day; 500mg-1/day

CAPRELSA TABLET 3 PA QL SP, 100mg-3/day; 300mg-1/day

COMETRIQ 5 PA QL SPN, 140mg/day

ERIVEDGE 3 PA QL SP, 1/day

FARYDAK 5 PA SP

GAZYVA 3 PA SP

GILOTRIF 3 PA QL SP, 1/day

GLEEVEC TABLET 3 PA QL SP, 2/day

IMBRUVICA 3 PA QL SP, 4/month

INLYTA TABLET 3 PA SPN, 1mg: 7 tabs/day, 5mg; 4 tabs/day

JAKAFI 3 PA QL SPN, 2 tabs/day

LENVIMA 3 PA QL SP ; 24 mg/day

LYNPARZA 3 PA QL SPN, 448 capsules per 28 days

MEKINIST 3 PA QL SP, 1 tab/day

NEXAVAR TABLET 3 PA QL SPN, 4 tabs/day

PURIXAN 3 PA SP

SPRYCEL TABLET 3 PA QL SP, 20mg-2/day; all others -1/day

STIVARGA TABLET 3 PA QL SP, 84 tabs/28 days

SUTENT CAPSULE 3 PA QL SP, 1/day




PA ST QL COMMENTS

TAFINLAR 3 PA QL SP, 4/day

TARCEVA TABLET 3 PA QL SP, 25mg-2/day; 100,150mg-1/day

TASIGNA CAPSULE 3 PA QL SP, 120/30days

TYKERB TABLET 3 PA QL SP, 6 tab/day

VOTRIENT TABLET 3 PA QL SP, 120/30 days

XALKORI CAPSULE 3 PA QL SPN, 2/day

ZELBORAF TABLET 3 PA QL SPN, 240/30 days

ZOLINZA 3 PA QL SP, 4/day

ZYDELIG 5 PA QL SP, 2/day

ZYKADIA 3 PA QL SP, 5/day

Hepatitis B Therapy

BARACLUDE SOLUTION, TABLET 5 PA QL SP, sol-20ml/30 days;

tab 1/day

HEPSERA TABLET 5 PA QL SP, 1/day

TYZEKA TABLET 3 PA QL SP, 1/day

Hepatitis C Therapy

COPEGUS 5 PA SP

DAKLINZA 5 PA QL SP: 1/day

HARVONI 3 PA QL SP, 1/day

INCIVEK 5 PA SP

INFERGEN VIAL 3 PA SP

MODERIBA 3 SP

OLYSIO 5 PA SP

PEGASYS PROCLICK, SYRINGE, VIAL 3 PA SP

PEG-INTRON FE PA SP; Preferred Alternative: Pegasys

REBETOL CAPSULE 5 PA SP

ribapak dose pack 3 PA SP

ribasphere capsule, tablet 3 PA SPN

RIBATAB 5 PA SP

ribavirin capsule, tablet 3 PA SPN

SOVALDI 3 PA QL SP, 1/day




PA ST QL COMMENTS

TECHNIVIE 5 PA QL SP: 2/day

VICTRELIS CAPSULE 3 PA SP

VIEKIRA PAK 5 PA QL SP; 4/day

Immune Globulins

GAMMAGARD INJECTION SOLUTION 3 PA QL SP;male: 36/day, female: 33/day

GAMUNEX- C 3 PA QL SP; male: 36/day, female: 33/day

GAMMAKED 5 PA QL SP; 36/day, female: 33/day

HIZENTRA 3 PA QL SP; male 20/day, female 18/day

HYQVIA 5 PA QL SP; male: 25/day, female: 22/day

Immunosuppressive Agents, Oral

ASTAGRAF XL 5 SP

AZASAN TABLET 2

azathioprine tablet 1

CELLCEPT ORAL SUSPENSION 3 SP

CELLCEPT CAPSULES, TABLET 5 SP

cyclosporine capsule, softgel, solution 3 SP

gengraf capsule, solution 3 SP

HECORIA capsule 3 SP

mycophenolate capsule, tablet 3 SP

MYFORTIC TABLET 5 SP

NEORAL 5 SP

PROGRAF AMPULES 3 SP

PROGRAF CAPSULES 5 SP

RAPAMUNE SOLUTION 3 SP

RAPAMUNE 0.5MG TABLETS 5 SP

RAPAMUNE 1MG,2MG TABLETS; ORAL

SOLUTION

3 SP

SANDIMMUNE ORAL SOLUTION 3 SP

SANDIMMUNE CAPSULES 5 SP

Sirolimus tablet 3 SP

tacrolimus capsule 3 SP

ZORTRESS TABLET 3 PA SP




PA ST QL COMMENTS

Selective Estrogen Receptor Modulators

anastrozole 1

FARESTON TABLET 2

FASLODEX SYRINGE MED

flutamide 1

exemestane 1

letrozole 1

tamoxifen tablet 1

Steroid Antineoplastics

EMCYT CAPSULE 3 SP

megestrol tablet 1

CARDIOVASCULAR MEDICATIONS

Anaphylaxis

epinephrine auto-injector 1

EPIPEN AUTO-INJECTOR 2

EPIPEN JR AUTO-INJECTOR 2

AUVI-Q 2 PA

Antiarrhythmics

amiodarone tablet 1

CORLANOR 2 PA QL 2/day

flecainide tablet 1

mexiletine capsule 1

pacerone tablet 1

procainamide capsule, tablet 1

propafenone capsule er, tablet 1

quinadine gluconate tablet er 1

quinidine sulfate tablet, tablet er 1

TIKOSYN CAPSULE 3 SP

ACE Inhibitors and HCTZ Combinations

benazepril tablet 1

benazepril/hctz tablet 1

captopril tablet 1




PA ST QL COMMENTS

captopril/hctz tablet 1

enalapril tablet 1

enalapril/hctz tablet 1

fosinopril tablet 1

fosinopril/hctz tablet 1

lisinopril tablet 1

lisinopril/hctz tablet 1

moexipril tablet 1

moexipril/hctz tablet 1

perindopril tablet 1

quinapril tablet 1

quinapril/hctz tablet 1

ramipril tablet 1

trandolapril tablet 1

Angiotensin II Receptor Blockers (ARB) and HCTZ Combinations

AMTURNIDE 4

ATACAND* 4 PA QL Dose Optimization: 2/day

ATACAND HCT 4 PA QL Dose Optimization: 1/day

AVALIDE 4 PA QL Dose Optimization: 1/day

AVAPRO 4 PA QL Dose Optimization: 1/day

BENICAR/HCTZ 2 QL Dose Optimization: 1/day

candesartan/hctz tablet 1 QL Dose Optimization: 1/day

COZAAR 4 PA

DIOVAN TABLET* 4

QL Dose Optimization: 2/day

Covered alternatives: valsartan

DIOVAN HCT 4 QL Dose Optimization: 1/day

EDARBI FE

Covered alternatives:

candesartan, irbesartan, losartan, Benicar

EDARBYCLOR

FE

Covered alternatives:

candesartan/hydrochloro-

thiazide (HCTZ), irbesartan/HCTZ,

losartan/HCTZ, valsartan/HCTZ, Benicar/HCT

eprosartan tablet 1

HYZAAR 4 PA




PA ST QL COMMENTS

irbesartan tablet 1 QL Dose Optimization: 1/day

irbesartan/hctz tablet 1 QL Dose Optimization: 1/day

losartan tablet 1

losartan/hctz tablet 1

MICARDIS* FE QL Covered alternatives:


MICARDIS HCT* FE QL Covered alternatives:




TEKAMLO 2

TEVETEN FE PA Covered alternatives:


TEVETEN HCT FE PA Covered alternatives:




TWYNSTA 4 PA Covered alternatives:

Azor, amlodipine/valsartan, Tribenzor

telmisartan 1

valsartan 1 QL Dose Optimization: 2/day

valsartan/hctz tablet 1

ACE or ARB + Calcium Channel Blocker Combinations

amlodipine/benazepril 1

amlodipine/valsartan 1

AZOR 2

EXFORGE* TABLET 4 Generic available: amlodipine/valsartan

EXFORGE HCT* TABLET 2

trandolapril/verapamil ER 1

TRIBENZOR 2

Beta Blockers and Alpha/Beta Blockers

acebutolol capsule 1

atenolol tablet 1

atenolol/chlorthalidone tablet 1




PA ST QL COMMENTS

betaxolol tablet 1

bisoprolol tablet 1

bisoprolol/HCTZ tablet 1

carvedilol tablet 1

DUTOPROL TABLET 4 Covered Alternatives: metoprolol succinate +

hydrochlorothiazide

labetalol tablet 1

metoprolol tablet 1

metoprolol succinate tablet er 1

metoprolol tartrate tablet 1

metoprolol/HCTZ tablet 1

nadolol tablet 1

nadolol/bendroflumethiazide tablet 1

pindolol tablet 1

propranolol capsule ER 1

propranolol tablet 1

propranolol/HCTZ tablet 1

sorine tablet 1

sotalol tablet 1

sotalol af tablet 1

timolol tablet 1

Calcium Channel Blockers

amlodipine tablet 1

cartia xt capsule 1

dilt-cd capsule, er capsule 1

diltia xt capsule 1

diltiazem, capsule CD, ER, SA, XR; tablet 1

dilt-XR capsule, SA 1

diltaz capsule ER 1

felodipine tablet ER 1

isradipine capsule 1

matzim tablet LA 1




PA ST QL COMMENTS

nicardipine capsule 1

nifediac tablet CC 1

nifedical tablet XL 1

nifedipine tablet, ER, XR 1

nisoldipine tablet ER 1

SULAR 4 PA QL Dose Optimization: 1/day

taztia capsule XT 1

verapamil capsule, tablet, ER, SA 1

Digitalis Glycosides

digitek tablet 1

digoxin tablet, solution 1

Hypotensives, Other

clonidine patch, tablet 1

Clorpres 0.1-15MG, 0.2-15MG tablet 1

DEMSER CAPSULE 2

guanfacine 1

hydralazine tablet 1

hydra-zide capsule 1

methyldopa tablet 1

methyldopa/HCTZ tablet 1

minoxidil tablet 1

reserpine tablet 1

Lipid Lowering Agents, Miscellaneous

ANTARA 4 PA

cholestyramine/light packet, powder 1

colestipol granules, tablet 1

fenofibrate capsule, tablet 1

fenofibric acid tablet 1

FENOGLIDE 4 PA

gemfibrozil tablet 1

JUXTAPID CAPSULE 3 PA QL SPN, 60mg/day

KYNAMRO 5 PA QL SP, 4 syr/28days




PA ST QL COMMENTS

LIPOFEN 4 PA

LOVAZA CAPSULE 4 Generic Alternative: omega-3 acid ethyl esters

omega-3 acid ethyl esters 1

NIASPAN*, NIASPAN ER TABLET 2

Prevalite packet, powder 1

TRICOR TABLET 2

TRIGLIDE 4 PA

TRILIPIX* 2

ZETIA TABLET 2

Lipid Lowering Agents, Statins and Combinations

ADVICOR 4 Covered Alternatives: lovastatin + Niaspan

ALTOPREV 4 PA

atorvastatin tablet 1

amlodipine/atorvastatin tablet 1

CRESTOR 2 QL Dose Optimization: 1/day

fluvastatin tablet 1 QL Dose Optimization: 2/day

LESCOL 4 PA

LESCOL XL 4 PA

LIPTRUZET 2 PA

LIVALO 4 PA

lovastatin tablet 1

MYALEPT 3 PA QL SP, 1vial/day

pravastatin tablet 1

simvastatin tablet 1

VYTORIN 2

Pulmonary Hypertension Agents/Pulmonary Fibrosis Agents

ADCIRCA TABLET 3 PA QL SP, 2/day

ADEMPAS 3 PA QL SP, 3/day

ESBRIET 3 PA QL SP, 9/day

LETAIRIS TABLET 3 PA QL SPN, 1/day

OFEV 3 PA QL SP; 2/day

OPSUMIT 3 PA QL SP, 1/day




PA ST QL COMMENTS

ORENITRAM ER 5 PA QL SP, 0.125MG(3/day), 0.25MG(6/day),

1MG(4/day), 2.5MG(6/day)

REVATIO TABLET, VIAL, ORAL SUSPENSION 5 PA QL SP, tablet 3/day; injection (3vials/day)

suspension (6ml/day)

sildenafil 20 mg tablet 3 PA QL SP, 3/day

TRACLEER TABLET 3 PA QL SPN, 2/day

TYVASO INHALATION SOLUTION 3 PA QL SPN, 1.74MG/2.9 (3 ampules/day)

VENTAVIS SOLUTION 3 PA QL SPN; 10, 20mcg/vial (9 ampules/day)

Diuretics

acetazolamide tablet 1

amiloride tablet 1

amiloride/HCTZ tablet 1

bumetanide tablet 1

chlorothiazide tablet 1

eplerenone tablet 1

furosemide tablet, solution 1

hydrochlorothiazide 1

indapamide tablet 1

methazolamide tablet 1

methyclothiazide 1

metolazone tablet 1

SAMSCA TABLET 3 PA QL SP: 2/day

spironolactone tablet 1

spironolactone/hydrochlorothiazide tablet 1

torsemide tablet 1

triamterene/hctz capsule, tablet 1

Vasodilators

isosorbide dinitrate tablet 1

isosorbide mononitrate tablet 1

isoxsuprine tablet 1

nitrek patch 1

nitrobid ointment 1

nitroglycerin patch 1




PA ST QL COMMENTS

nitroglycerine sublingual tablet 1

nitroglycerin ointment 1

nitroglycerin spray 1

nitroglycerin capsule ER, SA, TD 1

NITROLINGUAL 4

nitroquick sublingual tablet 1

nitrostat sublingual tablet 1

papaverine capsule 1

Vasopressors

NORTHERA 4 PA QL 180/month

CENTRAL NERVOUS SYSTEM

Anti-Alcoholic Preparations

disulfiram tablet 1

Anti-Anxiety Agents

alprazolam orally dissolving tablet, oral

concentrate, tablet, ER tablet

1

buspirone tablet 1

chlordiazepoxide capsule 1

clorazepate tablet 1

diazepam solution, tablet 1

lorazepam oral concentrate, tablet 1

oxazepam capsule 1

Antidepressants

BRINTELLIX 4 PA

Bupropion 1

Buproprion SR, XL 1

CYMBALTA* 4 QL 2/day: Generic Alternative: Duloxetine

duloxetine 1 QL 2/day

FETZIMA 2 PA

mirtazapine orally dissolving tablet, tablet 1

Phenelzine tablet 1

Tranylcypromine tablet 1

Trazodone tablet 1




PA ST QL COMMENTS

Venlafaxine capsule, ER tablet, tablet 1

Antidepressants, SSRIs

BRISDELLE 2

citalopram solution, tablet 1

escitalopram solution, tablet 1 QL Solution: 20.00ml/ day. Dose Optimization for

tablet: 1.6/day

fluoxetine capsule, solution, tablet 1

fluvoxamine tablet 1

paroxetine oral concentrate, suspension,

tablet

1

sertraline oral concentrate, tablet 1

selfemra capsule 1

fluoxetine/olanzapine capsule 1 QL Dose Optimization: 1/day

Antidepressants, Tricyclics, and Combination Agents

amitriptyline tablet 1

amoxapine tablet 1

clomipramine capsule 1

desipramine tablet 1

doxepin capsule, oral concentrate 1

imipramine capsule, tablet 1

maprotiline tablet 1

nortriptyline capsule, solution 1

protriptyline tablet 1

trimipramine capsule 1

amitriptyline/perphenazine tablet 1

amitriptyline/chlordiazepoxide tablet 1

Antimania Agents

lithium carbonate capsule, tablet 1

lithium ER tablet 1

lithium citrate solution, syrup 1

Antipsychotics

ABILIFY DISC MELT 4 PA QL

Dose Optimization: 2/day; Formulary

Alternative (aripiprazole)




PA ST QL COMMENTS

ABILIFY TABLET 4 PA QL

Dose Optimization: 1/day; Formulary

Alternative (aripiprazole)

ABILIFY SOLUTION 2 PA QL 25 ml /day

ABILIFY MAINTENA INJECTION 2 PA QL 1 injection/month

Aripiprazole disc melt, 1 QL Dose Optimization: 2/day

Aripiprazole tablet 1 QL Dose Optimization: 1/day

Aripiprazole solution 1 QL 25 ml/day

chlorpromazine tablet 1

clozapine orally dissolving tablet, tablet 1

FANAPT 4 PA QL 2/day; titration pak (8/claim)

fluphenazine tablet 1

GEODON 4 PA

haloperidol tablet 1

INVEGA ER 4 PA QL 1/day; 6MG(6/day)

INVEGA SUSTENNA* INJECTION 4 PA QL 1 injection/month

INVEGA TRINZA 4 PA QL 1 injection/3months

LATUDA 2 QL 1/day; (80MG 2/day)

loxapine capsule 1

olanzapine, orally dissolving tablet, tablet 1 QL Dose Optimization: 1/day

perphenazine tablet 1

quetiapine tablet 1

RISPERDAL CONSTA INJECTION 2 PA QL 1 injection/month

risperidone, m-tab, orally dissolving tablet,

solution, tablet

1

SAPHRIS 4 PA QL 2/day

SEROQUEL XR TABLET 2 QL 50MG, 300MG, 400MG (2/day); 150MG,

200MG (1/day)

thioridazine tablet 1

thiothixene tablet 1

trifluoperazine tablet 1

ziprasidone 1

ZYPREXA TABLETS, ZYDIS 4 PA QL Dose Optimization: 1/day

ZYPREXA RELPREVV 4 PA QL 1 injection/month




PA ST QL COMMENTS

Sedative/Hypnotics

AMBIEN 4 QL 1/day; (generic alternative: zolpidem)

AMBIEN CR 4 QL 1/day; (generic alternative: zolpidem ER)

BELSOMRA 4 PA QL 1/day

DORAL 4 QL 1/day generic alternative: quazepam

EDLUAR 4 PA QL 1/day

eszopiclone 1 QL 1/day

estazolam tablet 1 QL 1/day

flurazepam capsule 1 QL 1/day

HALCION 0.25MG 4 QL 2/day; generic alternative: triazolam

HETLIOZ 5 PA QL 1/day; SP

INTERMEZZO 4 PA QL 1/day

LUNESTA* 4 QL 1/day Generic Alternative: eszopiclone

quazepam 1 QL 1/day

RESTORIL 4 QL 1/day; generic alternative: temazepam

ROZEREM 2 PA QL 1/day

SILENOR 4 PA QL 1/day

SONATA 4 QL 1/day; generic alternative: zaleplon

temazepam capsule 1 QL 1/day

triazolam 1 QL 1/day; (0.25MG 2/day)

XYREM SOLUTION 3 SPN

zaleplon capsule 1 QL 1/day

zolpidem tablet 1 QL 1/day Gender edit max dose in women = 5mg

zolpidem ER tablet 1 QL 1/day gender edit max dose in women = 7.5mg

ZOLPIMIST 4 PA QL 1 bottle/month

Stimulants and Related ADHD Therapy

ADDERALL 4 QL 2/day

ADDERALL XR 4 QL 1/day

APTENSIO XR 4 QL 1/day

clonidine ER 1 QL 2/day: generic for kapvay

CONCERTA 4 QL 18MG, 27MG, 36MG (2/day), 54MG (1/day)

d-amphetamine salt combo tablet 1 QL 2/day




PA ST QL COMMENTS

d-amphetamine capsule, ER capsule 1 QL 1/day

DAYTRANA 2 QL 1/day

DESOXYN 4 QL 5/day

DEXEDRINE tablet 2 QL 5MG (2/day), 10MG(6/day)

DEXEDRINE ER 4 QL 5MG (2/day), 10MG (5/day), 15MG (4/day)

dexmethylphenidate tablet 1 QL 10MG (2/day), 2.5MG, 5MG (3/day) generic for

focalin

dexmethylphenidate capsule ER 1 QL 1/day; generic for focalin XR

dextroamphetamine/amphetamine ER

capsule

1 QL 5MG,10MG,15MG (1/day), 20MG, 25MG, 30MG

(2/day)

dextroamphetamine tablet, solution 1 QL 5MG (2/day), 10MG(6/day), solution

60ml/day

dextroamphetamine ER 1 QL 5MG (2/day), 10MG (5/day), 15MG (4/day)

EVEKEO 4 PA QL 6/day

FOCALIN 4 QL 2.5MG, 5MG (3/day), 10MG (2/day)

FOCALIN XR 4 QL 1/day (20MG, 2/day) generic available

INTUNIV 2 QL 1/day

KAPVAY 4 QL 2/day

METADATE CD 4 QL 1/day

METADATE ER (20MG tablet) 2 QL 3/day

methamphetamine 5MG tablet 1 QL 5/day

methylin tablet 1 QL 2.5MG, 5MG (3/day), 10MG (6/day)

methylin solution 1 QL 10MG/5ML (3/day), 5MG/5ML (6/day)

methylphenidate CD 1 QL 1/day

methylphenidate tablet 1 QL 10MG (5/day). 5MG, 20MG (3/day)

methylphenidate ER tablet (20MG) 1 QL 3/day (generic for metadate ER)

methylphendate ER capsule 1 QL 20MG, 40MG (1/day), 30MG (2/day)

methylphenidate ER 1 QL 18MG, 27MG, 36MG (2/day), 54MG (1/day)

methylphenidate LA 1 QL 1/day, 30MG(2/day)

methylphenidate solution 1 QL 10MG/5ML (3/day), 5MG/5ML (6/day)

methyphenidate SR 1 QL 3/day

modafinil tablet 1 PA QL 1/day

NUVIGIL 2 PA




PA ST QL COMMENTS

PROCENTRA SOLUTION 1 QL 60/day

PROVIGIL 4 PA QL 1/day

QUILLIVANT XR 2 QL 12/day

RITALIN 4 QL 5MG (3/day), 10MG(5/day), 20MG (3/day)

RITALIN LA 4 QL 1/day (30MG; 2/day)

RITALIN SR 4 QL 3/day

STRATTERA CAPSULE 2 QL 40MG, 60MG, 80MG, 100MG (1/DAY); 10MG,

18MG, 25MG (2/DAY

VYVANSE CAPSULE 4 QL 1/day

ZENZEDI 4 QL 2.5MG, 20MG (3/day), 5MG, 30MG (2/day),

7.5MG, 15MG (1/day), 10MG (6/day)

Opiate Dependence Treatments

BUNAVAIL 4 PA QL 2.1-0.3mg, 6.3-1mg (3/day), 4.2-0.7mg (2/day)

buprenorphine/naloxone tablet 1 PA QL 3/day

SUBOXONE FILM 2 PA QL 12-3mg, 4-1mg (2/day), 2-0.5mg, 8-2mg

(3/day)

ZUBSOLV 2 PA QL 3/day

Anticonvulsants

APTIOM 4 PA QL 1200mg/day

BANZEL SUSPENSION, TABLET 2

carbamazepine chew, suspension, tablet 1

carbamazepine er capsule, tablet 1

CELONTIN KAPSEAL 2

clonazepam orally dissolving, tablet 1

diazepam rectal gel 1

DILANTIN 30MG CAPSULE, INFATAB,

KAPSEAL

2

divalproex sodium, ER tablet 1

DUOPA 5 PA QL SP; 100/day

epitol tablet 1

felbamate suspensioin, tablet 1

fosphenytoin vial 1

FYCOMPA 2 PA QL 30/month




PA ST QL COMMENTS

GABITRIL TABLET 2

LAMICTAL ODT 4 generic available

lamotrigine dispertab, tablet ER tablet 1

levetiracetam solution, tablet, ER tablet 1

MEBARAL TABLET 2

mephobarbital tablet 1

ONFI TABLET 3 SP

oxcarbazepine suspension, tablet 1

OXTELLAR XR 2

phenobarbital solution, tablet 1

phenytoin capsule, chewable, suspension 1

POTIGA TABLET 2

primidone tablet 1

SABRIL POWDER PACKET, TABLET 3 SPN

TEGRETOL 200MG TABLET, XR 100MG

TABLET

2

tiagabine tablet 1

topiragen tablet 1

topiramate sprinkle, tablet 1

valproic acid capsule, syrup 1

VIMPAT TABLET, SOLUTION 2

zonisamide capsule 1

Alzheimer’s Agents

donepezil orally dissolving tablet, tablet 1 QL Dose Optimization: 1/day

galantamine, ER capsule, solution, tablet 1

NAMENDA SOLUTION, TABLET, XR 2

rivastigmine capsule 1

Antiparkinson Agents

APOKYN 3 SPN

AZILECT 2

benztropine tablet 1

bromocroptine capsule, tablet 1




PA ST QL COMMENTS

carbidopa/levodopa er tablet, orally

dissolving tablet, tablet

1

entacapone tablet 1

MIRAPEX ER* 2

ropinirole er tablet, tablet 1

selegiline capsule, tablet 1

trihexyphenidyl elixir, tablet 1

Multiple Sclerosis Agents

AUBAGIO 5 PA QL SPN, 1/day

AMPYRA ER TABLET 3 PA QL SP, 2/day

AVONEX INJECTION 3 PA QL SP, 4 syringes/28 days

BETASERON INJECTION FE QL SP, 14 syringes/28 days Covered alternatives:

Avonex, Rebif

COPAXONE INJECTION 3 PA QL SP, 20mg: 1/day;

40 mg: 0.43mg/day

EXTAVIA 3 PA QL SP, 15 syringes/30 days

GILENYA CAPSULE 3 PA QL SP, 1/day

PLEGRIDY 5 PA SP

REBIF INJECTION, REBIDOSE 3 PA QL SP, 6 syringes/28 days

TECFIDERA 3 PA QL SP, 2/day

Smoking Deterrents

buproban tablet 1 $0 copay; max 180 days therapy per 12 rolling

months

bupropion ER tablet 1 $0 copay; max 180 days therapy per 12 rolling

months

CHANTIX TABLET 2 QL 2/day: $0 copay; max 180 days therapy per 12

rolling months

NICOTINE PATCHES 1 $0 copay; max 180 days therapy per 12 rolling

months

NICOTROL NS 1 $0 copay; max 180 days therapy per 12 rolling

months

NICOTINE GUM/LOZENGES Rx and OTC 1 $0 copay; max 180 days therapy per 12 rolling

months




PA ST QL COMMENTS

DERMATOLOGIC MEDICATIONS

Antiacne Agents, Topical

ACANYA 2

ACZONE 4

adapalene cream, gel 1 PA over 26 years PA required

ATRALIN* GEL 2 PA over 26 years PA required

AVITA 4 PA over 26 years PA required

BENZACLIN GEL WITH PUMP FE

benzoyl peroxide cleanser, cream, foam, gel,

lotion, pads, wash

1

clindamycin phosphate/benzoyl peroxiede

gel

1

DIFFERIN 0.3% GEL, 0.1% LOTION 4 PA over 26 years PA required

DIFFERIN 0.1% CREAM, GEL 4 PA over 26 years PA required

EPIDUO 2

erythromycin/benzoyl peroxide 1

MIRVASO 2

ONEXTON FE

ORACEA 2

RETIN-A, MICRO 4 PA over 26 years PA required

SALICYLIC ACID 4

sodium sulfacetamide/sulfur lotion,

suspension

1

SOLODYN 55MG,65MG,80MG,105MG,115MG 2

TAZORAC GEL*, CREAM 2

tretinoin gel 1 PA over 26 years PA required

TRETIN-X 4 PA over 26 years PA required

VELTIN FE

ZENATANE 2

ZIANA 2

Antibiotic Agents, Topical

ALTABAX 4 PA Covered Alternatives: mupirocin

bacitracin ointment 1




PA ST QL COMMENTS

bacitracin/polymyxin ointment 1

clindamycin gel, foam, lotion, pledgets 1

erythromycin gel, pads, pledgets, solution 1

gentamicin cream, ointment 1

minocycline hcl 1

morgidox 1

mupirocin cream, ointment 1

neomycin/bacitracin/polymyxin ointment 1

neomycin/bacitracin/polymyxin/pramoxone

cream, ointment

1

Antifungal Agents, Topical

ciclopirox cream, gel, kit, shampoo, solution,

suspension

1

clotrimazole cream, solution 1

clotrimazole/Betamethasone cream, lotion 1

CRESEMBA 2 PA QL 6/day

JUBLIA 4 PA QL 2 bottles/month

ketoconazole cream, foam shampoo FE

KERYDIN 4 PA QL 2 bottles/month

LUZU 4 PA QL 60 gm/month

miconazole cream, powder, spray, ointment 1

NOXAFIL 2

nystatin cram, powder, ointment 1

nystatin/triamcinolone cream, ointment 1

terbinafine tablet 1

Antineoplastic Agents, Topical

fluorouracil cream, solution 1

TARGRETIN GEL 5 PA SP

VALCHLOR 3 SP

Antiparasitic Agents, Topical

EURAX CREAM, LOTION 4

lindane lotion, shampoo 1




PA ST QL COMMENTS

malathion lotion 1

permethrin cream 1

spinosad suspension 1

Antipsoriasis and Antieczema Drugs

calcipotriene cream, ointment, solution 1

TAZORAC CREAM, GEL 2

Antivirals, Topical

acyclovir ointment 1

DENAVIR 4

XERESE CREAM 4 Covered Alternatives:

acyclovir+hydrocortisone

ZOVIRAX CREAM, OINTMENT* 2

ZOVIRAX OINTMENT* 4 Generic Alternative: acyclovir ointment

Corticosteroids, Topical

aclometasone cream, ointment 1

amcinonide cream, lotion, ointment 1

betamethasone dipropionate cream, lotion,

gel ointment

1

betamethasone valerate cream, foam, lotion,

ointment

1

clobetasol cream, foam, gel, lotion, ointment,

shampoo

1

clobetasol emollient cream, foam 1

desonide cream, lotion, ointment 1

desoximetasone cream, gel, ointment 1

diflorasone cream, ointment 1

fluocinolone cream, oil, ointment, solution 1

fluocinonide cream, gel, ointment, solution 1

fluocinonide emollient cream 1

fluticasone cream, lotion, ointment 1

halobetasol cream, ointment 1

halobetasol/ammonium lactate kit 1

hydrocortisone cream, gel, lotion, ointment 1




PA ST QL COMMENTS

hydrocortisone butyrate cream, ointment,

solution

1

hydrocortisone valerate cream, ointment 1

mometasone cream, lotion, ointment,

solution

1

PRAMOSONE/PRAMOSONE E 4

prednicarbate cream, ointment 1

triamcinolone cream, lotion, ointment 1

Immunomodulators, Topical

ELIDEL 1% 2

imiquimod cream 1

PROTOPIC OINTMENT 4

tacrolimus ointment 1

ZYCLARA 4

Rosacea Agents

metronidazole cream, gel, lotion 1

rosadan cream, gel 1

EAR-NOSE MEDICATIONS

Antibiotics for the Ear

CETRAXAL FE PA

CIPRODEX 2

ciprofloxacin solution 1

CIPRO HC 4 PA

neomycin/polymyxin/hc solution,

suspension

1

ofloxacin solution 1

Antibiotics for the Nose

BACTROBAN NASAL OINTMENT 4 Alternative: mupirocin

Nasal Antihistamines

ASTEPRO SPRAY 2

ASTELIN 4

azelastine spray 1

olopatadine hcl 1




PA ST QL COMMENTS

PATANASE 4 PA

Nasal Corticosteroids

BECONASE AQ FE Covered Alternatives: flunisolide, fluticasone

propionate, triamcinolone acetonide, Nasonex, Qnasl

DYMISTA 2

FLONASE FE

flunisolide spray 1

fluticasone spray FE

NASACORT AQ FE

NASONEX* 2

OMNARIS

FE Covered Alternatives: flunisolide, fluticasone

propionate, triamcinolone acetonide, Nasonex,

Qnasl

QNASL 2

RHINOCORT AQUA



Qnasl

Triamcinolone acetonide spray FE

VERAMYST



Qnasl

ZETONNA



Qnasl

Nasal Mast Cell Stabilizers

cromolyn sodium solution, spray 1

ENDOCRINE MEDICATIONS

Amylin Analogs

SYMLIN, SYMLINPEN [INJ] 2

Androgenic Agents

ANDRODERM* 4

ANDROGEL 2

androxy tablet 1

AXIRON 2




PA ST QL COMMENTS

AVEED MED

FORTESTA FE Covered Alternatives: Androgel, Axiron

oxandrolone tablet 1

METHITEST TABLET 2

TESTIM FE Covered Alternatives: Androgel, Axiron

testosterone gel FE

testosterone vial [inj] 1

VOGELXO FE

Blood Sugar Diagnostics/Miscellaneous Supplies

ACCU-CHEK KITS; ACTIVE, ADVANTAGE,

AVIVA PLUS, COMPACT PLUS

FE

Covered Alternatives: ONETOUCH

ACCU-CHEK TEST STRIPS; ACTIVE, AVIVA

PLUS, COMFORT, CURVE, COMPACT DRUM

FE

Covered alternatives: ONETOUCH

BREEZE FE Covered alternatives: ONETOUCH

CONTOUR 4

PRECISION XTRA FE Covered alternatives: ONETOUCH

FREESTYLE 4

ONETOUCH KITS/METERS; BASIC, ULTRA 2,

ULTRAMINI, ULTRASMART, VERIO

2

ONETOUCH TEST STRIPS; FASTTAKE,

ONETOUCH, SURESTEP, ULTRA, VERIO

2

TRUETEST/TRUETRACK

FE


ACCU-CHEK LANCETS; MULTICLIX, SOFT

TOUCH, SOFTCLIX, FASTCLIX:

FE


INSULIN PEN NEEDLES 2

pen needles and syringes must have an insulin

or other covered injectable within the past 105

days

INSULIN NEEDLES:NOVOFINE NEEDLES; BD

NEEDLES

2



days

INSULIN SYRINGES 2



days




PA ST QL COMMENTS

Bone Resorption Inhibitors and Related

ACTONEL 4

alendronate tablet 1

calcitonin salmon spray 1

etidtronate tablet 1

EVISTA* TABLET 4

FORTEO PEN [INJ] 3 PA QL SP, 2.4 mL per 28 days

fortical spray 1

ibandronate tablet 1

MIACALCIN 3 SP

pamidronate vial [INJ] 1

raloxifene hcl 1

Corticotropins

H.P. ACTHAR 3 PA SPN

Dipeptidyl Peptidase-IV Inhibitors and Combos

JANUMET, XR TABLET 2

JANUVIA TABLET 2

JENTADUETO TABLET 2

JUVISYNC TABLET 2

KAZANO FE Covered alternatives: Janumet, Janumet XR,

Januvia, ,

KOMBIGLYZE XR FE Covered alternatives: Janumet, Janumet XR,

Januvia,

NESINA FE Covered alternatives: Janumet, Janumet XR,

Januvia,

ONGLYZA FE

OSENI 4 PA QL 30/month

TRADJENTA TABLET 2

Gaucher’s Disease

CERDELGA 3 PA QL SP; 2/day

ZAVESCA 3 PA QL SP; 300mg/day

Growth Hormone and Related Agents

EGRIFTA 5 PA QL SP, 2/day




PA ST QL COMMENTS

GENOTROPIN 3 PA SP

HUMATROPE 3 PA SP

INCRELEX 3 PA QL SP, 1/day

NORDITROPIN® cartridge, NORDIFLEX,

FLEXPRO (somatropin)

3 PA SP

NUTROPIN/NUTROPIN AQ FE SP: Covered Alternatives: Genotropin,

Humatrope, Norditropin

OMNITROPE FE SP: Covered Alternatives: Genotropin,


SAIZEN

FE SP: Covered Alternatives: Genotropin,

Humatrope, Norditropin; QL, 1mg, 60

vials/month2mg, 30 vials/month

SEROSTIM 5 PA QL SPN, 30vials/30 days

TEV-TROPIN FE SP, Covered Alternatives: Genotropin,


ZORBTIVE 5 PA QL SP, 28vials/28 days (1/day)

Incretin Mimetics

BYETTA [INJ] 2

BYDUREON VIAL [INJ], PEN 2

TANZEUM FE

TRULICITY 2 QL 4/28 days

VICTOZA FE

Insulins

AFREZZA FE

APIDRA FE Covered Alternatives: Humalog

HUMALOG CARTRIDGE, KWIKPEN, PEN,

VIAL [INJ]

2

HUMULIN, VIAL [INJ] 2

LANTUS VIAL [INJ] 2

LEVEMIR FLEXPEN, FLEXTOUCH, VIAL [INJ] 2

NOVOLIN FE Covered Alternatives: Humulin

NOVOLOG CARTRIDGE, FLEXPEN, VIAL [INJ] FE Covered Alternatives: Humalog

TOUJEO SOLOSTAR 2




PA ST QL COMMENTS

Insulin Sensitizers

ACTOPLUS MET XR TABLET 2

ACTOS 4 QL Dose Optimization: 1/day

pioglitazone tablet 1 QL Dose Optimization: 1/day

pioglitazone/glimepiride tablet 1

pioglitazone/metformin tablet 1

Oral Hypoglycemics

acarbose tablet 1

glimepiride tablet 1

glipizide, ER tablet 1

glipizide/metformin tablet 1

GLUMETZA ER 4 formulary alternatives: metformin er, riomet

solution

glyburide, micronized tablet 1

glyburide/metformin tablet 1

glycron tablet 1

metformin ER, tablet 1

nateglinide tablet 1

repaglinide 1

RIOMET SOLUTION 2

tolazamide tablet 1

tolbutamide tablet 1

Miscellaneous

HECTOROL 5 SP

OCTREOTIDE (SANDOSTATIN) 5 PA QL SP; 3/day

PARICALCITOL 3 SP

SIGNIFOR 3 PA QL SP, 60 ampules/30 days (2/day)

SIGNIFOR LAR 3 PA Ql SP; 0.04/day

STIMATE

3 QL SP, max 1 fill/182 days at any network

pharmacy, after that must fill at either ICore or

Shands

SYNAREL 3 PA SP

NATPARA 5 PA QL SP, 3/month




PA ST QL COMMENTS

vitamin D 1 $0 copay for members >/65 yrs old to prevent

bone fractures

ZEMPLAR 5 SP

SGLT2-inhibitor and combinations

FARXIGA 2 PA QL 30/month

GLYXAMBI 2 PA QL 30/month

INVOKANA 2 PA QL 30/month

Thyroid Supplements

ARMOUR THYROID TABLET 2

levothroid 1

levothyroxine sodium tablet 1

levoxyl tablet 1

liothyronine tablet, vial 1

Nature-Throid 1

thyroid tablet 1

unithroid tablet 1

westhroid tablet 1

GASTROINTESTINAL MEDICATIONS

Antinauseants

AKYNZEO 3 PA QL SP; 4/28 days

ALOXI VIAL [INJ] 2

CESAMET 5 SP

DICLEGIS 4 PA QL 4 tabs/day

dimenhydrinate tablet, vial 1

dronabinol capsule 1

EMEND CAPSULE, VIAL 2

granisetron solution, tablet, vial 1

meclizine chew tablet, tablet 1

ondansetron odt tablet, solution, tablet,

solution, vial

1

prochlorperazine suppository, tablet, vial 1

promethazine suppository 1

SANCUSO 3 SP




PA ST QL COMMENTS

TRANSDERM-SCOP 4

trimethobenzamide capsule, suppository 1

Anti-Ulcer Preparations

mistoprostol tablet 1

carafate suspension 1

sucralfate suspension, tablet 1

Bile Salts

CHENODAL TABLET 2

ursodiol capsule, tablet 1

Bowel Evacuants (generic Rx and OTC drugs for Bowel Prep to pay at ACA mandated $0 copay to people

aged 49 to 76)

bisacodyl 1

docusate 1

KRISTALOSE 4

lactulose 1

MOVIPREP 4

polyethylene glycol 1

PREPOPIK 2

Chronic Inflammatory Colon Disease/Miscellaneous Agents

APRISO 2 PA

ASACOL 4

ASACOL HD FE

balsalazide capsule 1

CANASA SUPPOSITORY 2

DELZICOL FE

GATTEX 5 SP

GIAZO 4 PA

LIALDA 2

mesalamine enema, kit 1

PENTASA CAPSULE 2

prednisone 1

Sulfasalazine 1




PA ST QL COMMENTS

Sulafazine DR 1

UCERIS 4 PA QL 30/month

Histamine H2 Receptor Blockers

cimetidine tablet, solution, vial 1

famotidine chewable, suspension, tablet 1

nizatidine capsule, solution 1

ranitidine capsule, syrup, tablet, vial FE

Intestinal Motility Stimulating Agents

metoclopramide ampule, solution, syrup,

tablet, vial

1

Opioid Induced Constipation

AMITIZA 2

MOVANTIK 2

Pancreatic Enzymes/Metabolic Disorders

CARNITOR IV, SOLUTION, TABLET 4

CHOLBAM 3 PA QL SP;7/day

CREON*, EC CAPSULE 2

ORKAMBI 3 PA QL SP; 4/day

PANCREAZE FE

pancrelipase DR 5,000, 17,000, 27,000 unit

cap

1

PERTZYE FE

ULTRESA FE

ZENPEP 3,000, 10,000, 15,000, 20,000,

25,000 UNITS

2

Proton Pump Inhibitors

ACIPHEX* 4 ST QL 1/day; (20mg 2/day) Trial of omeprazole, or omeprazole/sodium bicarbonate,

DEXILANT 4 ST QL 1/day ;Trial of omeprazole, or omeprazole/sodium bicarbonate, or lansoprazole, or pantoprazole

ESOMEPRAZOLE MAG DR 20MG, 40MG FE Over-the-counter Nexium is available alternative. Member responsible for 100% of cost

First-Lansoprazole FE ST Trial of omeprazole, or omeprazole/sodium bicarbonate




PA ST QL COMMENTS

First-Omeprazole FE ST Trial of omeprazole, or omeprazole/sodium bicarbonate

lansoprazole FE

NEXIUM (SUSPENSION) 4 PA PA required for >18 years of age

NEXIUM 20MG, 40MG CAPSULES, IV FE Over-the-counter Nexium is available alternative. Member responsible for 100% of cost

NEXIUM 24HR 22.3 MG (OTC) FE

omeprazole FE

pantoprazole FE QL 1/day

Prevacid FE

Prilosec caps, tabs, susp FE

Protonix 4 ST QL 1/day;Trial of omeprazole, or omeprazole/sodium bicarbonate

Rabeprazole 1 QL 1/day; (20mg 2/day)

Zegerid FE

IMMUNOLOGICALS

Hematopoietic Growth Factors

ARANESP 5 PA SPN; max 1 fill/182 days at any network pharmacy, after that must fill at either ICore or Shands

EPOGEN FE PA SPN

MIRCERA 5 PA SP

PROCRIT [INJ] 3 PA SPN

PROMACTA TABLET 3 PA QL SP, 2/day

BLOOD MODIFIERS

Antiplatelet/Antithrombin Agents/Miscellaneous

AGGRENOX CAPSULES 2

BRILINTA TABLET 2

BERINERT 3 PA QL SP; 1 vial

cilostazol tablet 1

CINRYZE 3 PA QL SP; 1 vial

clopidogrel tablet 1

dipyridamole tablet 1

EFFIENT TABLET 2

FIRAZYR 3 PA QL SP;1 vial

PRADAXA CAPSULE 2




PA ST QL COMMENTS

RUCONEST 5 PA QL SP; 1 vial

ZONTIVITY 2 PA QL 1 tab/day

Electrolyte Depleters and Chelators

calcium Acetate capsule, gelcap, tablet 1

eliphos tablet 1

EXJADE 3 PA QL SPN, 40mg per kg/day

FOSRENOL TAB CHEW 2

JADENU 3 PA SP

kionex suspension 1

RENAGEL* TAB 4 Covered Alternatives: Calcium Acetate,

Fosrenol, Renvela

RENVELA* PACKET, TABLET 2

sodium polystyrene sulfonate powder,

suspension

1

Hemorrheologic Agents

pentoxifylline ER tablet 1

Hemophilia Agents

ADVATE, L, M, H, SH UH 3 PA SP

ALPHANATE 3 PA SP

ALPHANINE SD 3 PA SP

ALPROLIX 3 PA SP

BENEFIX 3 PA SP

BEBULIN VH IMMUNO 3 PA SP

CORIFACT 3 PA SP

ELOCTATE 3 PA SP

FEIBA NF FEIBA, VH IMMUNO 3 PA SP

HELIXATE FS 3 PA SP

HEMOFIL-M 3 PA SP

HUMATE-P 3 PA SP

KOATE-DVI 3 PA SP

KOGENATE FS 3 PA SP

MONOCLATE-P 3 PA SP




PA ST QL COMMENTS

MONONINE 3 PA SP

NOVOEIGHT 5 PA SP

NOVOSEVEN RT 3 PA SP

PROFILNINE SD 5 PA SP

RECOMBINATE 3 PA SP

RIXUBIS 5 PA SP

TRETTEN 3 PA SP

WILATE 3 PA SP

XYNTHA 3 PA SP

XYNTHA SOLOFUSE 3 PA SP

Leukocyte Stimulants

GRANIX 300 mcg syringe, 480 mcg syringe 5 PA QL SP; 300mcg, 2/day, 480mcg, 1/day

LEUKINE [INJ] 250mcg vial, 500mcg vial 3 PA QL SP; 250mcg, 2/day, 500mcg,, 1/day

NEUPOGEN [INJ] 3 PA QL SP; 3/day

NEULASTA [INJ] 3 PA QL SP; 0.1/day

NEUMEGA 3 PA SP

Oral and Inj. Anticoagulants

ELIQUIS TABLET 2 PA QL 2 tabs/day

enoxaparin syringe, vial [INJ] 2 QL SP - max 1 fill/182 days at any network


Shands

fondaparinux syringe [INJ] /ARIXTRA

3/5 QL SP - max 1 fill/182 days at any network


Shands

FRAGMIN

5 QL SP - max 1 fill/182 days at any network


Shands

IPRIVASK

5 QL SP - max 1 fill/182 days at any network


Shands

warfarin tablet 1

XARELTO 2

OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS

Contraceptives




PA ST QL COMMENTS

NOTE: All generic contraceptives are zero dollar copay/coinsurance

altavera 1

alyacen 1

amethia 1

amethia lo 1

apri 1

aranelle 1

aviane 1

azurette 1

balziva 1

BEYAZ 2

briellyn 1

camila 1

camrese 1

camrese lo 1

caziant 1

cesia 1

chateal 1

cryselle 1

cyclafem 1

dasetta 1

drospirenone-ethinyl estradiol 1

elinest 1

emoquette 1

enpresse 1

errin 1

falmina 1

gianvi 1

gildagia 1

gildess 1

gildess fe 1

heather 1




PA ST QL COMMENTS

introvale 1

jolessa 1

jolivette 1

junel 1

junel fe 1

kariva 1

kelnor 1/35 1

kurvelo 1

leena 1

lessina 1

levonest 1

levonorgestrel 1

levonorgestrel-eth estradiol 1

levonorg-eth estrad eth estrad 1

levora-28 1

LO LOESTRIN FE 2

LOESTRIN 24 FE 2

Lo Ministran 24 Fe 2

loryna 1

marlissa 1

microgestin 1

microgestin fe 1

MINASTRIN 24 FE 2

mono-linyah 1

mononessa 1

my way 1

myzilra 1

NATAZIA 2

necon 1

next choice 1

next choice one dose 1

nora-be 1




PA ST QL COMMENTS

norethindrone 1

norgestimate-ethinyl estradiol 1

norgestrel-ethiny estra 1

nortrel 1

ocella 1

orsythia 1

philith 1

portia 1

previfem 1

quasense 1

reclipsen 1

SAFYRAL 2

solia 1

sprintec 1

sronyx 1

syeda 1

tilia fe 1

tri-legest fe 1

tri-linyah 1

tri-lo-sprintec 1

trinessa 1

tri-previfem 1

tri-sprintec 1

trivora-28 1

velivet 1

vestura 1

viorele 1

wera 1

wymzya fe 1

zarah 1

zenchent 1

zenchent fe 1




PA ST QL COMMENTS

zeosa 1

zovia 1-35e 1

Estrogens

CENESTIN 2

DIVIGEL 2

estradiol patch, tablet 1

estradiol valerate 1

ENJUVIA 2

ESTRING 4

estrogen, conjugated 1 QL Dose Optimization: 1/day

estropipate tablet 1

EVAMIST 4

MENEST TABLET 4

OSPHENA 4 PA QL 1 tab/day

ortho-est tablet 1

PREMARIN TABLET 2 QL Dose Optimization: 1/day

PREMARIN VAGINAL CREAM 2 QL 2gm/day

VAGIFEM VAGINAL TABLET 2

VIVELLE-DOT* 4

Estrogen Combinations

CLIMARA PRO* 4 Covered alternatives: estradiol patch+

medroxyprogesterone, combipatch

COMBIPATCH* 2

DUAVEE 2 PA QL 1 tab/day

estradiol/norethindrone acetate tablet 1

estrogen/methyltestosterone tablet (DS, FS,

HS)

1

jinteli tablet 1

mimvey tablet 1

PREMPHASE TABLET 2

PREMPRO TABLET 2

Infertility Agents

BRAVELLE 5 PA SP




PA ST QL COMMENTS

CHORIONIC GONADOTROPIN 3 PA SP

CETROTIDE 3 PA SP

FOLLISTIM AQ FE PA SP Preferred Alternatives: Gonal-F

GONAL-F 3 PA SP

GONAL-F RFF 3 PA SP

GANIRELIX ACETATE FE PA SP

LUVERIS 4 PA

MENOPUR 3 PA SP

NOVAREL 3 PA SP

OVIDREL 5 PA SP

PREGNYL 5 PA SP

REPRONEX 5 PA SP

Progestins

CRINONE GEL 2

ENDOMETRIN VAGINAL SUPP FE SP

FIRST-PROGESTERONE VGS FE Covered Alternative: Endometrin

MAKENA MED

medroxyprogesterone 1

norethindrone 1

progesterone capsules 1

Vaginal Antibiotic Agents

clindamycin vaginal cream 1

METROGEL 0.75% 4 Covered Alternatives: Metronidazole Gel

metronidazole vaginal gel 1

vandazole vaginal gel 1

Vaginal Antifungal Agents

clotrimazole cream, insert 1

miconazole cream, combo pack, vaginal

suppository

1

nystatin vaginal tablet 1

terconazole cream, vaginal suppository 1

OPHTHALMIC MEDICATIONS

Antibiotics and Steroid Combinations, Ophthalmic




PA ST QL COMMENTS

AZASITE 4

bacitracin ointment 1

bacitracin polymyxin ointment 1

BESIVANCE 4 PA

BETOPTIC S 4

ciprofloxacin drops 1

DUREZOL 4

erythromycin ointment 1

gentamicin drops, ointment 1

levofloxacin drops 1

MOXEZA DROPS 2

NATACYN DROPS 2

neomycin/polymyxin/bacitracin ointment 1

neomycin/polymyxin/gramicidin drops 1

neomycin/polymyxin/hc drops, ointment 1

ofloxacin drops 1

polymyxin/trimethoprim drops 1

tobramycin sulfate drops 1

TOBRADEX OINTMENT 2

tobrymycin/dexamethasone suspension 1

Anti-Inflammatories, Opththalmics

ACUVAIL 4 Covered Alternatives: Bromfenac, Diclofenac,

Bromday,Ilevro, Nevenac, Prolensa

ALREX 2

BROMDAY 4

bromfenac drops 1

dexamethasone drops, ointment 1

diclofenac drops 1

fluorometholone drops 1

flurbiprofen drops 1

ILEVRO 2

ketorolac solution 1

LOTEMAX 2




PA ST QL COMMENTS

NEVENAC 2

PRED-G EYE DROPS

FE Covered Alternatives: tobramycin/

dexamethasone suspension/ZYLET

PRED MILD DROPS 2

PROLENSA 2

prednisolone drops 1

RESTASIS* 2

ZYLET 2

Antihistamines, Ophthalmics

azelastine drops 1

BEPREVE 4 PA

EMADINE 4 PA

epinastine drops 1

PATADAY 2

PATANOL 2

PAZEO 2

Glaucoma Treatment

apraclonidine drops 1

ALPHAGAN P 0.1% DROPS 2

AZOPT DROPS* 4 Covered Alternatives: bromfenac, diclofenac,

BROMDAY, ILEVRO, NEVENAC, PROLENSA

betaxolol drops 1

BETOPIC S DROPS 2

brimonidine drops 1

carteolol drops 1

COMBIGAN 2

dorzolamide drops 1

dorzolamide/timolol drops 1

ISOPTO CARBACHOL DROPS 2

latanoprost drops 1

levobunolol drops 1

LUMIGAN* DROPS 2




PA ST QL COMMENTS

metipranolol drops 1

pilocarpine drops 1

RESCULA 4 ST QL 1 bottle/month; must try two preferred

products latanoprost, travoprost

SIMBRINZA 4 PA QL 1 bottle/month

timolol maleate trops 1

TRAVATAN Z* DROP 2

travoprost 1

XALATAN 4 ST Must try: latanoprost, travoprost, Lumigan, or

Travatan Z

ZIOPTAN FE Covered Alternatives: latanoprost, travoprost,

Lumigan, Travatan Z

Mast Cell Stabilizers, Ophthalmics

ALOCRIL 4 PA

ALOMIDE 4 PA

Cromolyn 1

RESPIRATORY MEDICATIONS

Antihistamines

cetirizine syrup 1

desloratadine odt, tablet 1

fexofenadine odt, tablet 1

levocetirizine solution, tablet 1

Beta Adrenergics

albuterol nebulizer, solution, tablet, syrup 1

BROVANA 4 PA

FORADIL AEROLIZER 2

levalbuterol nebulizer solution 1

MAXAIR AUTOHALER FE Covered Alternatives: Proair, Ventolin HFA

PERFOROMIST NEBULIZER SOLUTION 2

PROAIR HFA 2

PROVENTIL HFA FE Covered Alternatives: Proair, Ventolin HFA

RELION 4 Covered Alternatives: Proair, Ventolin HFA

terbutaline nebulizer solution, tablet 1




PA ST QL COMMENTS

VENTOLIN HFA 2

XOPENEX HFA FE PA Preferred Alternatives: Proair, Ventolin HFA

Beta Adrenergic/Glucocorticoid Combinations

ADVAIR DISKUS, HFA 2

SYMBICORT INHALER 2

DULERA 2

Beta Adrenergic/Anticholinergic Combinations

COMBIVENT, RESPIMAT 2

ipratropium/albuterol nebulizer solution 1

COPD Treatment

ANORO ELLIPTA 2 PA QL 1 package (14gm)/month

ARNUITY ELLIPTA 4 PA QL 1 inhaler/month

ATROVENT HFA 2

ipratropium solution 1

SPIRIVA HANDIHALER 2

STIOLTO RESPIMAT 2 PA QL 1 inhaler/month

TUDORZA PRESSAIR 2

Leukotriene Modifiers

montelukast chewable, granule, tablet 1 QL Dose Optimization: 1/day

zafirlukast tablet 1

Mucolytics

PULMOZYME 3 PA QL SP, 60 ampules/month (5.0/day)

Orally Inhaled Corticosteroids

ADVAIR DISKUS/HFA 2

ALVESCO FE ST Must try 2 preferred products: Asmanex,

Pulmicort Flexhaler, QVAR

AEROSPAN INHALER W/ADAPTER 4 PA QL 1 inhaler/month

ASMANEX 2

ASMANEX HFA 2

BREO ELLIPTA 2 PA

budesonide suspension 1

FLOVENT DISKUS/HFA FE ST




PA ST QL COMMENTS

PULMICORT FLEXHALER, RESPULE,

TURBUHALER

2

QVAR INHALER 2

Pollen Allergans

GRASTEK 2 PA

ORALAIR 4 PA

RAGWITEK 2 PA

Respiratory - Miscellaneous

KALYDECO 3 PA QL SP: 2/day

UROLOGICAL MEDICATIONS

Antispasmodics

DETROL LA* 4 QL Dose Optimization: 1/day

ENABLEX

4 Covered Alternatives: Oxybutynin Ext-Release,

Trospium Ext-Release, Detrol LA, Myrbetriq,

Toviaz, Vesicare

flavoxate tablet 1

GELNIQUE GEL 2

MYRBETRIQ 2

oxybutynin, er syrup, tablet 1 QL ER – 1/day

OXYTROL PATCH 4

SANCTURA XR 4 PA Dose Optimization: 1/day

Tolterodine ER 1

tolterodine tablet 1 QL Dose Optimization: 2/day

tolterodine la capsules 1

TOVIAZ ER 2

trospium er capsule, tablet 1 ST Must Try 1 Other Tier 1 Product First

VESICARE 2

BPH Therapy

alfuzosin ER tablet 1

doxazosin tablet 1

Finasteride 1mg tablet FE

prazosin capsule 1

RAPAFLO 2




PA ST QL COMMENTS

tamsulosin capsule 1

terazosin capsule 1

Erectile Dysfunction Agents

CAVERJECT 2 QL 6 units per 30 days

CIALIS 2 QL 6 tabs per 30 days

LEVITRA FE Covered alternatives: Cialis, Viagra

MUSE 2 QL 6 units per 30 days

STAXYN FE Covered alternatives: Cialis, Viagra

STENDRA FE

VIAGRA 2 QL 6 tabs per 30 days

Urologicals Miscellaneous

PROCYSBI 5 SP



Index

A

abacavir tablet ................................................................. 17 ABILIFY DISC MELT ........................................................ 31 ABILIFY MAINTENA INJECTION .................................... 32 ABILIFY SOLUTION ......................................................... 32 ABILIFY TABLET ............................................................. 32 ACANYA ........................................................................... 38 acarbose tablet ................................................................ 46 acebutolol capsule ........................................................... 25 acetaminophen/butalbital/caffeine/codeine capsule .. 10 acetaminophen/butalbital/caffeine/codeine tablet ..... 10 acetaminophen/codeine ................................................. 10 acetazolamide tablet ....................................................... 29 ACIPHEX........................................................................... 49 aclometasone cream, ointment ...................................... 40 ACTEMRA SYRINGE .......................................................... 9 ACCU-CHEK KITS ............................................................. 43 ACCU-CHEK TEST STRIPS ............................................... 43 ACTONEL ......................................................................... 44 ACTOPLUS MET XR TABLET .......................................... 46 ACTOS .............................................................................. 46 ACUVAIL .......................................................................... 58 acyclovir capsule, suspension, tablet ............................. 16 acyclovir ointment .......................................................... 40 adapalene cream, gel ....................................................... 38 ADCIRCA TABLET ........................................................... 28 ADDERALL ....................................................................... 33 ADDERALL XR ................................................................. 33 ADEFOVIR DIPIVOXIL ..................................................... 20 ADEMPAS ......................................................................... 28 ADVAIR DISKUS, HFA ...................................................... 61 ADVATE ........................................................................... 51 ADVICOR .......................................................................... 28 AEROSPAN ....................................................................... 61 AFINITOR, DISPERZ ........................................................ 20 AGGRENOX CAPSULES .................................................... 50 AKYNZEO ......................................................................... 47 ALBENZA TABLET ........................................................... 16 albuterol nebulizer, solution, tablet, syrup ................... 60 alendronate tablet ........................................................... 44 alfuzosin ER tablet .......................................................... 62 ALKERAN TABLET .......................................................... 19 allopurinol ......................................................................... 9 ALOCRIL ........................................................................... 60 ALOMIDE ......................................................................... 60 ALOXI VIAL [INJ] ............................................................. 47 ALPHAGAN P 0.1% DROPS ............................................. 59 ALPHANATE .................................................................... 51

ALPHANINE SD ............................................................... 51 alprazolam orally dissolving tablet, oral concentrate,

tablet, ER tablet .......................................................... 30 ALPROLIX ........................................................................ 51 ALREX .............................................................................. 58 ALTABAX ......................................................................... 38 altavera ............................................................................ 53 ALTOPREV ....................................................................... 28 ALVESCO ......................................................................... 61 alyacen ............................................................................. 53 amantadine ..................................................................... 17 AMBIEN ........................................................................... 33 AMBIEN CR...................................................................... 33 amcinonide cream, lotion, ointment .............................. 40 amethia ............................................................................ 53 amethia lo ........................................................................ 53 amiloride tablet .............................................................. 29 amiloride/HCTZ tablet ................................................... 29 amiodarone tablet .......................................................... 23 AMITIZA .......................................................................... 49 amitriptyline tablet ......................................................... 31 amitriptyline/chlordiazepoxide tablet .......................... 31 amitriptyline/perphenazine tablet ............................... 31 amlodipine tablet ............................................................ 26 amlodipine/atorvastatin tablet ..................................... 28 amlodipine/benazepril .................................................. 25 amlodipine/valsartan ..................................................... 25 amoxapine tablet ............................................................ 31 amoxicillin chewable, capsule, suspension, tablet ....... 14 amoxicillin/clavulanate chewable, suspension, tablet . 14 ampicillin capsule, suspension ...................................... 14 AMPYRA ER TABLET ...................................................... 37 AMTURNIDE.................................................................... 24 anastrozole ...................................................................... 23 ANDRODERM .................................................................. 42 ANDROGEL ...................................................................... 42 androxy tablet ................................................................. 42 ANORO ELLIPTA ............................................................. 61 ANTARA ........................................................................... 27 APIDRA ............................................................................ 45 APOKYN ........................................................................... 36 apraclonidine drops ....................................................... 59 apri ................................................................................... 53 APRISO ............................................................................ 48 APTENSIO XR .................................................................. 33 APTIOM ........................................................................... 35 APTIVUS CAPSULE, SOLUTION ...................................... 17 aranelle ............................................................................ 53 ARANESP ......................................................................... 50 Aripiprazole .................................................................... 32



ARMOUR THYROID TABLET .......................................... 47 ARNUITY ELLIPTA .......................................................... 61 ASACOL ............................................................................ 48 ASACOL*, EC, HD ............................................................. 48 ASMANEX ......................................................................... 61 ASMANEX HFA ................................................................ 61 aspirin/codeine tablet .................................................... 10 ASTELIN ........................................................................... 41 ASTEPRO SPRAY ............................................................. 41 ATACAND ......................................................................... 24 ATACAND HCT ................................................................. 24 atenolol tablet .................................................................. 25 atenolol/chlorthalidone tablet ....................................... 25 atorvastatin tablet ........................................................... 28 atovaquone-proganil tablet ............................................ 16 ATRALIN* GEL ................................................................. 38 ATRIPLA TABLET ............................................................ 17 ATROVENT HFA .............................................................. 61 AUBAGIO .......................................................................... 37 AUGMENTIN SUSPENSION ............................................. 14 AUVI-Q ............................................................................. 23 AVALIDE .......................................................................... 24 AVAPRO ........................................................................... 24 AVEED .............................................................................. 43 AVELOX* TAB, ABC pack................................................. 14 aviane ............................................................................... 53 avidoxy tablet .................................................................. 15 AVINZA ............................................................................. 10 AVITA ............................................................................... 38 AVONEX INJECTION ........................................................ 37 AXERT ................................................................................ 9 AXIRON ............................................................................ 42 AZASAN TABLET ............................................................. 22 AZASITE ........................................................................... 58 azathioprine tablet .......................................................... 22 azelastine drops .............................................................. 59 azelastine spray ............................................................... 41 AZILECT ........................................................................... 36 azithromycin powder packet, suspension, tablet ......... 14 AZOPT DROPS ................................................................. 59 AZOR ................................................................................ 25 azurette ............................................................................ 53

B

bacitracin ointment ................................................... 38, 58 bacitracin polymyxin ointment ...................................... 58 bacitracin/polymyxin ointment ..................................... 39 baclofen tablet ................................................................. 13 BACTROBAN NASAL OINTMENT ................................... 41 balsalazide capsule.......................................................... 48 balziva .............................................................................. 53 BANZEL SUSPENSION, TABLET ..................................... 35 BARACLUDE SOLUTION, TABLET .................................. 21 ONETOUCH KITS/METERS ............................................. 43 BEBULIN VH IMMUNO .................................................... 51 BECONASE AQ ................................................................. 42 BELSOMRA ...................................................................... 33

benazepril tablet ............................................................. 23 benazepril/hctz tablet .................................................... 23 BENEFIX .......................................................................... 51 BENICAR/HCTZ .............................................................. 24 BENZACLIN GEL ............................................................. 38 benzoyl peroxide cleanser, cream, foam, gel, lotion,

pads, wash .................................................................. 38 benztropine tablet .......................................................... 36 BEPREVE ......................................................................... 59 BERINERT ....................................................................... 50 BESIVANCE ..................................................................... 58 betamethasone dipropionate cream, lotion, gel ointment

..................................................................................... 40 betamethasone valerate cream, foam, lotion, ointment

..................................................................................... 40 BETASERON INJECTION ................................................. 37 betaxolol drops ............................................................... 59 betaxolol tablet ............................................................... 26 Bethkis ............................................................................. 13 BETOPIC S DROPS........................................................... 59 BETOPTIC S ..................................................................... 58 BEYAZ .............................................................................. 53 bicalutamide tablet ......................................................... 19 bisacodyl ......................................................................... 48 bisoprolol tablet .............................................................. 26 bisoprolol/HCTZ tablet .................................................. 26 BOSULIF TABLET ............................................................ 20 BRAVELLE ....................................................................... 56 BREEZE/CONTOUR ........................................................ 43 briellyn ............................................................................ 53 BRILINTA TABLET .......................................................... 50 brimonidine drops .......................................................... 59 BRINTELLIX .................................................................... 30 BRISDELLE ...................................................................... 31 BROMDAY ....................................................................... 58 bromfenac drops ............................................................. 58 bromocroptine capsule, tablet ....................................... 36 BROVANA ........................................................................ 60 budesonide suspension .................................................. 61 bumetanide tablet ........................................................... 29 BUNAVAIL ....................................................................... 35 buprenorphine syringe .................................................. 10 buprenorphine/naloxone tablet .................................... 35 buproban tablet .............................................................. 37 bupropion ER tablet ....................................................... 37 buspirone tablet .............................................................. 30 butorphanol spray, syringe, vial .................................... 10 BYDUREON VIAL [INJ] .................................................... 45 BYETTA [INJ]................................................................... 45

C

calcipotriene cream, ointment, solution ....................... 40 calcitonin salmon spray ................................................. 44 calcium Acetate capsule, gelcap, tablet ......................... 51 camila .............................................................................. 53 camrese ........................................................................... 53 camrese lo ....................................................................... 53 CANASA SUPPOSITORY .................................................. 48



candesartan/hctz tablet .................................................. 24 Capcitabine ...................................................................... 19 CAPRELSA TABLET ......................................................... 20 captopril tablet ................................................................ 23 captopril/hctz tablet ....................................................... 24 carafate suspension ........................................................ 48 carbamazepine chew, suspension, tablet ...................... 35 carbamazepine er capsule, tablet ................................... 35 carbidopa/levodopa er tablet, orally dissolving tablet,

tablet ........................................................................... 37 CARNITOR ....................................................................... 49 carteolol drops ................................................................ 59 cartia xt capsule ............................................................... 26 carvedilol tablet ............................................................... 26 CAVERJECT ...................................................................... 63 caziant .............................................................................. 53 cefaclor suspension, capsule .......................................... 13 cefadroxil suspension, tablet .......................................... 13 cefdinir capsule, suspension ........................................... 13 cefditoren pivoxil tablet .................................................. 13 cefpodoxime suspension, tablet ..................................... 13 cefprozil suspension, tablet ............................................ 13 cefuroxime tablet ............................................................ 13 CELEBREX CAPSULE ....................................................... 12 celecoxib .......................................................................... 12 CELLCEPT ORAL SUSPENSION ....................................... 22 CELONTIN KAPSEAL ....................................................... 35 CENESTIN ........................................................................ 56 cephalexin suspension, capsule ..................................... 13 CERDELGA ....................................................................... 44 CESAMET ......................................................................... 47 cesia .................................................................................. 53 cetirizine syrup................................................................ 60 CETRAXAL ....................................................................... 41 CETROTIDE ...................................................................... 57 CHANTIX TABLET ........................................................... 37 chateal .............................................................................. 53 CHENODAL TABLET ....................................................... 48 chlordiazepoxide capsule ............................................... 30 chloroquine tablet ........................................................... 16 chlorothiazide tablet ....................................................... 29 chlorpromazine tablet .................................................... 32 chlorzoxazone tablet ....................................................... 13 CHOLBAM ........................................................................ 49 cholestyramine/light packet, powder ........................... 27 CHORIONIC GONADOTROPIN ........................................ 57 CIALIS ............................................................................... 63 ciclopirox cream, gel, kit, shampoo, solution, suspension

..................................................................................... 39 CIDOFOVIR ...................................................................... 17 cilostazol tablet ............................................................... 50 cimetidine tablet, solution, vial ...................................... 49 CIMZIA ............................................................................. 10 CINRYZE ........................................................................... 50 CIPRO 5% SUSPENSION .................................................. 14 CIPRO ER .......................................................................... 14 CIPRO HC ......................................................................... 41 CIPRO TABLET ................................................................ 14 CIPRODEX ........................................................................ 41

ciprofloxacin drops ......................................................... 58 ciprofloxacin ER .............................................................. 14 ciprofloxacin solution ..................................................... 41 ciprofloxacin tablet ......................................................... 14 citalopram solution, tablet ............................................. 31 clarithromycin suspension, tablet, ER ........................... 14 CLIMARA PRO ................................................................. 56 clindamycin gel, foam, lotion, pledgets ......................... 39 clindamycin phosphate/benzoyl peroxiede gel............ 38 clindamycin vaginal cream ............................................ 57 clobetasol cream, foam, gel, lotion, ointment, shampoo

..................................................................................... 40 clobetasol emollient cream, foam .................................. 40 clomipramine capsule .................................................... 31 clonazepam orally dissolving, tablet ............................. 35 clonidine patch, tablet .................................................... 27 clopidogrel tablet ............................................................ 50 clorazepate tablet ........................................................... 30 clorpres tablet ................................................................. 27 clotrimazole cream, insert ............................................. 57 clotrimazole cream, solution.......................................... 39 clotrimazole troche ......................................................... 15 clotrimazole/Betamethasone cream, lotion ................. 39 clozapine orally dissolving tablet, tablet ....................... 32 COARTEM TABLET ......................................................... 16 codeine tablet .................................................................. 10 COLCRYS ............................................................................ 9 colestipol granules, tablet .............................................. 27 COMBIGAN ...................................................................... 59 COMBIPATCH .................................................................. 56 COMBIVENT, RESPIMAT ................................................ 61 COMBIVIR ........................................................................ 17 COMETRIQ ...................................................................... 20 COMPLERA ...................................................................... 17 CONCERTA ...................................................................... 33 CONZIP ............................................................................ 10 COPAXONE INJECTION ................................................... 37 COPEGUS ......................................................................... 21 CORLANOR ...................................................................... 23 COSENTYX ....................................................................... 10 COZAAR ........................................................................... 24 CREON*, EC CAPSULE ..................................................... 49 CRESEMBA ...................................................................... 39 CRESTOR ......................................................................... 28 CRINONE GEL .................................................................. 57 CRIXIVAN CAPSULE ........................................................ 17 cromolyn sodium solution, spray .................................. 42 Cromolynv ....................................................................... 60 cryselle ............................................................................ 53 cyclafem........................................................................... 53 cyclobenzaprine, tablet .................................................. 13 CYCLOPHOSPHAMIDE CAPSULE ................................... 19 cyclophosphamide tablet ............................................... 19 cyclosporine capsule, softgel, solution .......................... 22 CYMBALTA ...................................................................... 30



D

DAKLINZA ........................................................................ 21 d-amphetamine capsule, ER capsule.............................. 34 d-amphetamine salt combo tablet ................................. 33 dantrolene capsule .......................................................... 13 DARAPRIM TABLET ........................................................ 16 dasetta .............................................................................. 53 DAYTRANA ...................................................................... 34 DELZICOL ......................................................................... 48 demeclocycline tablet ..................................................... 15 DEMSER CAPSULE .......................................................... 27 desipramine tablet .......................................................... 31 desloratadine odt, tablet ................................................. 60 desonide cream, lotion, ointment................................... 40 desoximetasone cream, gel, ointment ........................... 40 DESOXYN ......................................................................... 34 DETROL LA ...................................................................... 62 dexamethasone drops, ointment .................................... 58 DEXEDRINE CAPSULE..................................................... 34 DEXEDRINE SPANSULE .................................................. 34 DEXILANT ........................................................................ 49 dexmethylphenidate tablet............................................. 34 dextroamphetamine ER .................................................. 34 dextroamphetamine tablet ............................................. 34 dextroamphetamine/amphetamine ER capsule ........... 34 diazepam rectal gel ......................................................... 35 diazepam solution, tablet................................................ 30 DICLEGIS .......................................................................... 47 diclofenac drops .............................................................. 58 diclofenac sodium drops (topical) ................................. 12 diclofenac sodium tablet, enteric ................................... 12 diclofenac/misoprostol tablet ........................................ 12 dicloxacillin capsule ........................................................ 15 didanosine capsule .......................................................... 17 DIFFERIN 0.1% CREAM, GEL .......................................... 38 DIFFERIN 0.3% GEL, 0.1% LOTION ............................... 38 diflorasone cream, ointment .......................................... 40 digitek tablet .................................................................... 27 digoxin tablet, solution ................................................... 27 dihydroergotamine ........................................................... 9 diltaz capsule ER ............................................................. 26 dilt-cd capsule, er capsule ............................................... 26 diltia xt capsule................................................................ 26 dilt-XR capsule, SA........................................................... 26 dimenhydrinate tablet, vial ............................................ 47 DIOVAN HCT .................................................................... 24 DIOVAN TABLET ............................................................. 24 dipyridamole tablet ......................................................... 50 disulfiram tablet .............................................................. 30 divalproex sodium, ER .................................................... 35 DIVIGEL ............................................................................ 56 docusate ........................................................................... 48 donepezil orally dissolving tablet, tablet ....................... 36 dorzolamide drops .......................................................... 59 dorzolamide/timolol drops ............................................ 59 doxazosin tablet .............................................................. 62 doxepin capsule, oral concentrate ................................. 31

doxycycline capsule, tablet, suspension ........................ 15 dronabinol capsule ......................................................... 47 drospirenone-ethinyl estradiol ...................................... 53 DUAVEE ........................................................................... 56 DUEXIS ............................................................................ 12 DULERA ........................................................................... 61 duloxetine ....................................................................... 30 DUOPA ............................................................................. 35 DUREZOL ......................................................................... 58 DUTOPROL TABLET ....................................................... 26 DYMISTA ......................................................................... 42

E

EDARBI ............................................................................ 24 EDARBYCLOR .................................................................. 24 EDLUAR ........................................................................... 33 EDURANT TABLET ......................................................... 17 EES GRANULES, FILMTAB.............................................. 14 EFFIENT TABLET............................................................ 50 EGRIFTA .................................................................... 44, 45 elinest .............................................................................. 53 eliphos tablet................................................................... 51 ELIQUIS TABLET ............................................................. 52 ELOCTATE ....................................................................... 51 EMADINE ......................................................................... 59 EMCYT CAPSULE ............................................................ 23 EMEND CAPSULE, VIAL .................................................. 47 emoquette ....................................................................... 53 EMTRIVA CAPSULE, SOLUTION..................................... 17 ENABLEX ......................................................................... 62 enalapril tablet ................................................................ 24 enalapril/hctz tablet ....................................................... 24 ENBREL ........................................................................... 10 ENDOMETRIN SUPP ...................................................... 57 ENJUVIA ........................................................................... 56 enoxaparin syringe, vial [INJ] ........................................ 52 enpresse .......................................................................... 53 entacapone tablet ........................................................... 37 ENTYVIO .......................................................................... 10 EPIDUO ............................................................................ 38 epinastine drops ............................................................. 59 EPIPEN AUTO-INJECTOR ............................................... 23 EPIPEN JR AUTO-INJECTOR ........................................... 23 epitol tablet ..................................................................... 35 Epivir HBV ....................................................................... 17 EPIVIR* SOLUTION ......................................................... 17 eplerenone tablet ............................................................ 29 EPOGEN ........................................................................... 50 eprosartan tablet ............................................................ 24 EPZICOM TABLET ........................................................... 17 ergotamine-caffeine.......................................................... 9 ERIVEDGE ....................................................................... 20 errin ................................................................................. 53 ERYPED SUSPENSION .................................................... 14 ERY-TAB .......................................................................... 14 ERY-TAB EC TABLET ...................................................... 14 erythrocin filmtab ........................................................... 14



erythromycin capsule, tablet, ec tablet, suspension, granules....................................................................... 14

erythromycin gel, pads, pledgets, solution .................... 39 erythromycin ointment .................................................. 58 erythromycin/benzoyl peroxide .................................... 38 erythromycin/sulfisoxazole suspension ....................... 14 ESBRIET ........................................................................... 28 escitalopram solution, tablet .......................................... 31 ESOMEPRAZOLE ............................................................. 49 estazolam tablet .............................................................. 33 estradiol patch, tablet ..................................................... 56 estradiol valerate ............................................................ 56 estradiol/norethindrone acetate tablet ......................... 56 estrogen, conjugated ....................................................... 56 estrogen/methyltestosterone tablet (DS, FS, HS) ......... 56 estropipate tablet ............................................................ 56 eszopiclone ...................................................................... 33 ethambutol tablet ............................................................ 16 etidtronate tablet ............................................................ 44 etodolac ............................................................................ 12 EURAX CREAM, LOTION ................................................. 39 EVAMIST .......................................................................... 56 EVEKEO ............................................................................ 34 EVISTA* TABLET ............................................................. 44 EVOTAZ ............................................................................ 17 EXALGO ............................................................................ 11 exemestane ...................................................................... 23 EXFORGE HCT* TABLET ................................................. 25 EXFORGE* TABLET ......................................................... 25 EXJADE ............................................................................. 51 EXTAVIA .......................................................................... 37

F

FACTIVE ........................................................................... 14 falmina ............................................................................. 53 famciclovir tablet ............................................................ 17 famotidine chewable, suspension, tablet, vial ............... 49 FANAPT ............................................................................ 32 FARESTON TABLET ........................................................ 23 FARXIGA........................................................................... 47 FARYDAK ......................................................................... 20 FASLODEX SYRINGE ....................................................... 23 ONETOUCH TEST STRIPS ............................................... 43 FEIBA NF .......................................................................... 51 felbamate suspensioin, tablet ......................................... 35 felodipine tablet ER ......................................................... 26 fenofibrate capsule, tablet .............................................. 27 fenofibric acid tablet ....................................................... 27 FENOGLIDE ...................................................................... 27 fenoprofen tablet ............................................................. 12 fentanyl patch .................................................................. 11 FENTORA ......................................................................... 11 FETZIMA .......................................................................... 30 finasteride table .............................................................. 62 FIRAZYR ........................................................................... 50 First-Lansoprazole .......................................................... 49 First-Omeprazole ............................................................ 50

FIRST-PROGESTERONE VGS .......................................... 57 flavoxate tablet ............................................................... 62 flecainide tablet .............................................................. 23 FLECTOR PATCH ............................................................ 12 FLONASE ......................................................................... 42 FLOVENT DISKUS/HFA .................................................. 61 fluconazole suspension, tablet ....................................... 15 flucytosine capsule ......................................................... 15 flunisolide spray ............................................................. 42 fluocinolone cream, oil, ointment, solution .................. 40 fluocinonide cream, gel, ointment, solution .................. 40 fluocinonide emollient cream, ointment ....................... 40 fluorometholone drops .................................................. 58 fluorouracil cream, solution ........................................... 39 fluoxetine capsule, solution, tablet ................................ 31 fluoxetine/olanzapine capsule....................................... 31 fluphenazine tablet ......................................................... 32 flurazepam capsule ......................................................... 33 flurbiprofen drops .......................................................... 58 flurbiprofen tablet .......................................................... 12 flutamide ......................................................................... 23 flutamide capsule ............................................................ 19 fluticasone cream, lotion, ointment ............................... 40 fluticasone spray ............................................................. 42 fluvastatin tablet ............................................................. 28 fluvoxamine tablet .......................................................... 31 FOCALIN .......................................................................... 34 FOLLISTIM AQ................................................................. 57 fondaparinux syringe [INJ] ............................................ 52 FORADIL AEROLIZER ..................................................... 60 FORTEO PEN [INJ] .......................................................... 44 FORTESTA ....................................................................... 43 fortical spray ................................................................... 44 fosinopril tablet .............................................................. 24 fosinopril/hctz tablet ..................................................... 24 fosphenytoin vial ............................................................ 35 FOSRENOL TAB CHEW ................................................... 51 FREESTYLE ..................................................................... 43 FROVA ............................................................................... 9 furosemide tablet, solution ............................................ 29 FUZEON KIT, VIAL .......................................................... 17 FYCOMPA ........................................................................ 35

G

gabapentin capsule, solution, tablet .............................. 12 GABITRIL TABLET .......................................................... 36 galantamine, ER capsule, solution, tablet ...................... 36 GAMMAGARD LIQUID .................................................... 22 GAMMAKED .................................................................... 22 GAMUNEX ........................................................................ 22 ganciclovir capsule ......................................................... 17 GANIRELIX ACETATE ..................................................... 57 GATTEX ........................................................................... 48 GAZYV .............................................................................. 20 GELNIQUE GEL ................................................................ 62 gemfibrozil tablet ........................................................... 27 gengraf capsule, solution ................................................ 22



GENOTROPIN .................................................................. 45 gentamicin cream, ointment ........................................... 39 gentamicin drops, ointment ........................................... 58 GEODON ........................................................................... 32 gianvi ................................................................................ 53 GIAZO ............................................................................... 48 gildagia ............................................................................. 53 gildess .............................................................................. 53 gildess fe .......................................................................... 53 GILENYA CAPSULE .......................................................... 37 GILOTRIF ......................................................................... 20 GLEEVEC TABLET ........................................................... 20 glimepiride tablet ............................................................ 46 glipizide, ER tablet........................................................... 46 glipizide/metformin tablet ............................................. 46 GLUMETZA ER ................................................................. 46 glyburide, micronized tablet .......................................... 46 glyburide/metformin tablet ........................................... 46 glycron tablet ................................................................... 46 GLYXAMBI........................................................................ 47 GONAL-F .......................................................................... 57 GONAL-F RFF ................................................................... 57 GRALISE ........................................................................... 12 granisetron solution, tablet, vial .................................... 47 GRANIX ............................................................................ 52 GRASTEK .......................................................................... 62 griseofulvin micro tablet ................................................ 15 griseofulvin suspension .................................................. 15 griseofulvin ultra tablet .................................................. 15 guanfacine ........................................................................ 27

H

H.P. ACTHAR .................................................................... 44 halobetasol cream, ointment .......................................... 40 halobetasol/ammonium lactate kit ................................ 40 haloperidol tablet ............................................................ 32 HARVONI ......................................................................... 21 heather ............................................................................. 53 hecoria capsule ................................................................ 22 HELIXATE FS ................................................................... 51 HEMOFIL-M ..................................................................... 51 HEPSERA TABLET ........................................................... 21 HETLIOZ........................................................................... 33 HEXALEN CAPSULE ........................................................ 19 HIVID TABLET ................................................................. 17 HIZENTRA ........................................................................ 22 HUMALOG CARTRIDGE, KWIKPEN, PEN, VIAL ............. 45 HUMATE-P ....................................................................... 51 HUMATROPE ................................................................... 45 HUMIRA ........................................................................... 10 HUMULIN, VIAL [INJ] ...................................................... 45 HYCAMTIN ....................................................................... 19 hydralazine tablet ........................................................... 27 hydra-zide capsule .......................................................... 27 hydrochlorothiazide........................................................ 29 hydrocodone/acetaminophen tablet ............................. 11 hydrocodone/ibuprofen tablet ...................................... 11

hydrocortisone butyrate cream, ointment, solution .... 41 hydrocortisone cream, gel, lotion, ointment ................. 40 hydrocortisone valerate cream, ointment .................... 41 hydromorphone solution ............................................... 11 hydroxychloroquine tablet ............................................ 16 hydroxyurea capsule ...................................................... 19 HYQVIA ............................................................................ 22 HYSINGLA ER .................................................................. 11 HYZAAR ........................................................................... 24

I

ibandronate tablet .......................................................... 44 ibuprofen tablet .............................................................. 12 ILEVRO ............................................................................ 58 IMBRINZA........................................................................ 60 IMBRUVICA ..................................................................... 19 imipramine capsule, tablet ............................................. 31 imiquimod cream ............................................................ 41 IMITREX, nasal .................................................................. 9 INCIVEK ........................................................................... 21 INCRELEX ........................................................................ 45 indapamide tablet ........................................................... 29 indomethacin capsule, ER .............................................. 12 INFERGEN VIAL .............................................................. 21 INLYTA TABLET ............................................................. 20 INSULIN NEEDLES

NOVOFINE NEEDLES ................................................. 43 INSULIN PEN NEEDLES .................................................. 43 INSULIN SYRINGES ......................................................... 43 INTELENCE TABLET ...................................................... 17 INTERMEZZO .................................................................. 33 introvale .......................................................................... 54 INTUNIV .......................................................................... 34 INVEGA SUSTENNA* INJECTION ................................... 32 INVEGA TRINZA .............................................................. 32 INVIRASE CAPSULE, TABLET ........................................ 17 INVOKANA ...................................................................... 47 ipratropium solution ...................................................... 61 ipratropium/albuterol nebulizer solution .................... 61 irbesartan tablet ............................................................. 25 irbesartan/hctz tablet .................................................... 25 ISENTRESS CHEWABLE, TABLET .................................. 17 isoniazid solution, tablet ................................................ 16 ISOPTO CARBACHOL DROPS ......................................... 59 isosorbide dinitrate tablet ............................................. 29 isosorbide mononitrate tablet ....................................... 29 isoxsuprine tablet ........................................................... 29 isradipine capsule ........................................................... 26 itraconazole capsule ....................................................... 15

J

JADENU ............................................................................ 51 JAKAFI ............................................................................. 20 JANUMET, XR TABLET ................................................... 44 JANUVIA TABLET ............................................................ 44 JENTADUETO TABLET ................................................... 44



jinteli tablet...................................................................... 56 jolessa .............................................................................. 54 jolivette ............................................................................ 54 JUBLIA .............................................................................. 39 junel.................................................................................. 54 junel fe.............................................................................. 54 JUVISYNC TABLET ........................................................... 44 JUXTAPID CAPSULE ........................................................ 27

K

KADIAN ............................................................................ 11 KALETRA SOFTGEL, SOLUTION,TABLET ...................... 17 KALYDECO ....................................................................... 62 KAPVAY ............................................................................ 34 kariva ............................................................................... 54 KAZANO ........................................................................... 44 kelnor 1/35 ...................................................................... 54 KERYDIN .......................................................................... 39 ketoconazole cream, foam shampoo .............................. 39 ketoconazole tablet ......................................................... 15 ketoprofen capsule, ER ................................................... 12 ketorolac solution ........................................................... 58 ketorolac tablet ............................................................... 12 KINERET .......................................................................... 10 kionex suspension ........................................................... 51 KOATE-DVI ...................................................................... 51 KOGENATE FS ................................................................. 51 KOMBIGLYZE XR ............................................................. 44 KRISTALOSE .................................................................... 48 kurvelo ............................................................................. 54 KYNAMRO ........................................................................ 27

L

labetalol tablet ................................................................. 26 lactulose ........................................................................... 48 LAMISIL GRANULES ........................................................ 15 lamivudine tablet ............................................................ 18 lamivudine/zidovudine tablet ........................................ 18 lamotrigine dispertab, tablet ER tablet .......................... 36 lansoprazole, odt ............................................................. 50 LANTUS VIAL [INJ] .......................................................... 45 latanoprost drops ............................................................ 59 LATUDA ........................................................................... 32 LAZANDA ......................................................................... 11 leena ................................................................................. 54 leflunomide ...................................................................... 10 LESCOL ............................................................................. 28 LESCOL XL ....................................................................... 28 lessina .............................................................................. 54 LETAIRIS TABLET ........................................................... 28 letrozole ........................................................................... 23 LEUKERAN TABLET ........................................................ 19 LEUKINE [INJ] ................................................................. 52 leuprolide acetate ............................................................ 19 levalbuterol nebulizer solution ...................................... 60 LEVAQUIN ........................................................................ 14

LEVEMIR FLEXPEN, VIAL [INJ] ...................................... 45 levetiracetam solution, tablet, ER tablet ....................... 36 LEVITRA .......................................................................... 63 levobunolol drops ........................................................... 59 levocetirizine solution, tablet ........................................ 60 levofloxacin drops .......................................................... 58 levofloxacin tablet, solution ........................................... 14 levonest ........................................................................... 54 levonorgestrel ................................................................. 54 levonorgestrel-eth estradiol .......................................... 54 levonorg-eth estrad eth estrad ...................................... 54 levora-28 ......................................................................... 54 levorphanol ..................................................................... 11 levothroid ........................................................................ 47 levothyroxine sodium tablet .......................................... 47 levoxyl tablet ................................................................... 47 LEXIVA SUSPENSION, TABLET ...................................... 18 LIALDA ............................................................................ 48 lidocaine 5% patch ......................................................... 12 lidocaine cream, ointment.............................................. 12 LIDODERM PATCH ......................................................... 12 lindane lotion, shampoo ................................................. 39 liothyronine tablet, vial .................................................. 47 LIPOFEN .......................................................................... 28 LIPTRUZET ...................................................................... 28 lisinopril tablet................................................................ 24 lisinopril/hctz tablet ....................................................... 24 lithium carbonate capsule, tablet .................................. 31 lithium citrate solution, syrup ....................................... 31 lithium ER tablet ............................................................. 31 LIVALO ............................................................................ 28 LO LOESTRIN FE ............................................................. 54 LOESTRIN 24 FE ............................................................. 54 lorazepam oral concentrate, tablet ................................ 30 loryna............................................................................... 54 losartan tablet ................................................................. 25 losartan/hctz tablet ........................................................ 25 LOTEMAX ........................................................................ 58 lovastatin tablet .............................................................. 28 LOVAZA CAPSULE ........................................................... 28 loxapine capsule ............................................................. 32 LUMIGAN* DROPS .......................................................... 59 LUNESTA ......................................................................... 33 LUPRON DEPOT .............................................................. 20 LUVERIS .......................................................................... 57 LUZU ................................................................................ 39 LYNPARZA ....................................................................... 20 LYRICA CAPSULE, SOLUTION ........................................ 12 LYSODREN ...................................................................... 20

M

MAKENA .......................................................................... 57 malathion lotion.............................................................. 40 maprotiline tablet ........................................................... 31 marlissa ........................................................................... 54 matzim tablet LA ............................................................. 26 MAXAIR AUTOHALER .................................................... 60



MAXALT, MLT .................................................................... 9 MEBARAL TABLET .......................................................... 36 mebendazole chew tablet ............................................... 16 meclizine chew tablet, tablet .......................................... 47 meclofenamate capsule .................................................. 12 medroxyprogesterone .................................................... 57 mefenamic acid capsule .................................................. 12 mefloquine tablet ............................................................ 16 megestrol tablet .............................................................. 23 MEKINIST ........................................................................ 20 meloxicam tablet ............................................................. 12 MENEST TABLET ............................................................ 56 MENOPUR ........................................................................ 57 mephobarbital tablet ...................................................... 36 mercaptopurine tablet .................................................... 19 mesalamine enema, kit ................................................... 48 MESNEX ........................................................................... 20 METADATE ER ................................................................ 34 metaxalone tablet ............................................................ 13 metformin ER, tablet ....................................................... 46 methadone ....................................................................... 11 methamphetamine tablet ............................................... 34 methazolamide tablet ..................................................... 29 METHITEST TABLET ...................................................... 43 methocarbamol tablet ..................................................... 13 methotrexate ................................................................... 10 methyclothiazide ............................................................. 29 methyldopa tablet ........................................................... 27 methyldopa/HCTZ tablet ................................................ 27 methylin er tablet, tablet ................................................ 34 methylin solution ............................................................ 34 methylphendate ER capsule ........................................... 34 Methylphenidate CD........................................................ 34 methylphenidate cd capsule, er tablet, la capsule, sr

tablet, solution, tablet ................................................ 34 methylphenidate ER tablet ............................................. 34 methylphenidate tablet ................................................... 34 metipranolol drops ......................................................... 60 metoclopramide ampule, solution, syrup, tablet, vial ... 49 metolazone tablet ............................................................ 29 metoprolol succinate tablet er ....................................... 26 metoprolol tablet............................................................. 26 metoprolol tartrate tablet ............................................... 26 metoprolol/HCTZ tablet ................................................. 26 METROGEL ...................................................................... 57 metronidazole cream, gel, lotion .................................... 41 metronidazole tablet ....................................................... 16 metronidazole vaginal gel............................................... 57 mexiletine capsule ........................................................... 23 MIACALCIN ...................................................................... 44 MICARDIS ........................................................................ 25 MICARDIS HCT ................................................................ 25 miconazole cream, combo pack, vaginal suppository ... 57 miconazole cream, powder, spray, ointment ................ 39 microgestin ...................................................................... 54 microgestin fe .................................................................. 54 mimvey tablet .................................................................. 56 MINASTRIN 24 FE ........................................................... 54 MINOCYCLINE HCL ......................................................... 39

minocycline, ER capsule ................................................. 15 minoxidil tablet ............................................................... 27 MINTEZOL CHEW TABLET, SUSPENSION .................... 16 MIRAPEX ER .................................................................... 37 MIRCERA ......................................................................... 50 mirtazapine orally dissolving tablet, tablet .................. 30 MIRVASO ......................................................................... 38 mistoprostol tablet ......................................................... 48 modafinil tablet ............................................................... 34 MODERIBA ...................................................................... 21 moexipril tablet .............................................................. 24 moexipril/hctz tablet...................................................... 24 mometasone cream, lotion, ointment, solution ............ 41 MONOCLATE-P ............................................................... 51 mono-linyah .................................................................... 54 mononessa ...................................................................... 54 MONONINE ..................................................................... 52 montelukast chewable, granule, tablet ......................... 61 MORGIDOX ...................................................................... 39 morgidox capsule ............................................................ 15 morphine solution, ER tablet ......................................... 11 Morphine Sulfate Extended Release .............................. 11 MOVANTIK ...................................................................... 49 MOVIPREP ....................................................................... 48 MOXEZA DROPS .............................................................. 58 MS CONTIN ...................................................................... 11 ACCU-CHEK LANCETS .................................................... 43 mupirocin cream, ointment ........................................... 39 MUSE ............................................................................... 63 my way ............................................................................ 54 MYALEPT......................................................................... 28 MYCOBUTIN CAPSULE ................................................... 16 mycophenolate capsule, tablet ...................................... 22 MYFORTIC TABLET ........................................................ 22 MYLERAN TABLET ......................................................... 19 MYRBETRIQ .................................................................... 62 myzilra ............................................................................. 54

N

nabumetone tablet.......................................................... 12 nadolol tablet .................................................................. 26 nadolol/bendroflumethiazide tablet ............................. 26 NAMENDA SOLUTION, TABLET .................................... 36 naproxen tablet, suspension .......................................... 12 naratriptan ........................................................................ 9 NASACORT ...................................................................... 42 NASONEX......................................................................... 42 NATACYN DROPS ............................................................ 58 NATAZIA .......................................................................... 54 nateglinide tablet ............................................................ 46 Nature-Throid ................................................................. 47 necon ............................................................................... 54 neomycin ......................................................................... 16 neomycin/bacitracin/polymyxin ointment .................. 39 neomycin/bacitracin/polymyxin/pramoxone cream,

ointment ..................................................................... 39 neomycin/polymyxin/bacitracin ointment .................. 58



neomycin/polymyxin/gramicidin drops ....................... 58 neomycin/polymyxin/hc drops, ointment .................... 58 neomycin/polymyxin/hc solution, suspension ............ 41 NEORAL ........................................................................... 22 NESINA ............................................................................. 44 NEULASTA [INJ] .............................................................. 52 NEUMEGA ........................................................................ 52 NEUPOGEN [INJ] ............................................................. 52 NEVENAC ......................................................................... 59 nevirapine suspension, tablet ........................................ 18 NEXAVAR TABLET .......................................................... 20 NEXIUM ............................................................................ 50 next choice ....................................................................... 54 next choice one dose ....................................................... 54 NIASPAN*, NIASPAN ER TABLET ................................... 28 nicardipine capsule ......................................................... 27 NICOTINE ......................................................................... 37 nifediac tablet CC ............................................................. 27 nifedical tablet XL ............................................................ 27 nifedipine tablet, ER, XR ................................................. 27 NILANDRON TABLET ...................................................... 19 nisoldipine tablet ER ....................................................... 27 nitrek patch ..................................................................... 29 nitrobid ointment ............................................................ 29 nitrofurantion macro/monohydrate capsule ................ 18 nitrofurantoin capsule, suspension ............................... 18 nitrofurantoin macro capsule ......................................... 18 nitroglycerin capsule ER, SA, TD .................................... 30 nitroglycerin ointment .................................................... 30 nitroglycerin patch .......................................................... 29 nitroglycerin spray .......................................................... 30 nitroglycerine sublingual tablet ..................................... 30 NITROLINGUAL ............................................................... 30 nitroquick sublingual tablet ........................................... 30 nitrostat sublingual tablet .............................................. 30 nizatidine capsule, solution ............................................ 49 nora-be ............................................................................. 54 Norditropin® cartridge, Nordiflex, FlexPro

(somatropin) ............................................................... 45 norethindrone ........................................................... 55, 57 norgestimate-ethinyl estradiol ....................................... 55 norgestrel-ethiny estra ................................................... 55 NOROXIN ......................................................................... 14 NORTHERA ...................................................................... 30 nortrel .............................................................................. 55 nortriptyline capsule, solution ....................................... 31 NORVIR SOFTGEL CAPSULE, TABLET ........................... 18 NOVAREL ......................................................................... 57 NOVOEIGHT ..................................................................... 52 NOVOLIN .......................................................................... 45 NOVOLOG CARTRIDGE, FLEXPEN, VIAL [INJ] ............... 45 NOVOSEVEN RT .............................................................. 52 NOXAFIL SUSPENSION ................................................... 15 NUCYNTA ......................................................................... 11 NUTROPIN/NUTROPIN AQ ............................................ 45 NUVIGIL ........................................................................... 34 nystain powder, suspension, tablet ............................... 15 nystatin cram, powder, ointment ................................... 39 nystatin vaginal tablet .................................................... 57

nystatin/triamcinolone cream, ointment ..................... 39

O

ocella ................................................................................ 55 OCTREOTIDE .................................................................. 46 OFEV ................................................................................ 28 ofloxacin drops ............................................................... 58 ofloxacin solution ........................................................... 41 ofloxacin tablet ............................................................... 14 olanzapine, orally dissolving tablet, tablet ................... 32 OLYSIO ............................................................................. 21 omeprazole ..................................................................... 50 OMNARIS ......................................................................... 42 OMNITROPE .................................................................... 45 ondansetron odt tablet, solution, tablet, solution, vial . 47 ONEXTON ........................................................................ 38 ONFI TABLET .................................................................. 36 ONGLYZA ......................................................................... 44 ONSOLIS .......................................................................... 11 OPANA ER ....................................................................... 11 OPSUMIT ......................................................................... 28 ORACEA ........................................................................... 38 ORALAIR .......................................................................... 62 ORENCIA ......................................................................... 10 ORENITRAM ER .............................................................. 29 ORKAMBI......................................................................... 49 orphenadrine tablet, ER ................................................. 13 orsythia ........................................................................... 55 ortho-est tablet ............................................................... 56 OSENI ............................................................................... 44 OSPHENA......................................................................... 56 OVIDREL .......................................................................... 57 oxandrolone tablet ......................................................... 43 oxaprozin caplet, tablet .................................................. 12 oxazepam capsule ........................................................... 30 oxcarbazepine suspension, tablet .................................. 36 oxybutynin, er syrup, tablet ........................................... 62 oxycodone capsule, solution, tablet ............................... 11 Oxycodone ER ................................................................. 11 oxycodone/acetaminophen tablet ................................. 11 OXYCONTIN..................................................................... 11 oxymorphone tablet ....................................................... 11 OXYTROL PATCH ............................................................ 62

P

pacerone tablet ............................................................... 23 pamidronate vial [INJ] .................................................... 44 PANCREAZE .................................................................... 49 pancrelipase DR .............................................................. 49 pantoprazole ................................................................... 50 papaverine capsule ......................................................... 30 PARICALCITOL ................................................................ 46 paroxetine oral concentrate, suspension, tablet ........... 31 PATADAY ......................................................................... 59 PATANASE....................................................................... 42 PATANOL......................................................................... 59



PEGASYS PROCLICK, SYRINGE, VIAL ............................. 21 PEG-INTRON .................................................................... 21 penicillin vk suspension, tablet ...................................... 15 PENNSAID ........................................................................ 12 PENTASA CAPSULE ......................................................... 48 pentoxifylline ER tablet .................................................. 51 PERFOROMIST NEBULIZER SOLUTION ........................ 60 perindopril tablet ............................................................ 24 permethrin cream, lotion, rinse, shampoo .................... 40 perphenazine tablet ........................................................ 32 PERTZYE .......................................................................... 49 Phenelzine tablet ............................................................. 30 phenobarbital solution, tablet ........................................ 36 phenytoin capsule, chewable, suspension ..................... 36 philith ............................................................................... 55 pilocarpine drops ............................................................ 60 pindolol tablet ................................................................. 26 pioglitazone tablet........................................................... 46 pioglitazone/glimepiride tablet ..................................... 46 pioglitazone/metformin tablet....................................... 46 piroxicam capsule ........................................................... 12 polyethylene glycol ......................................................... 48 polymyxin/trimethoprim drops .................................... 58 POMALYST CAPSULE ...................................................... 19 portia ................................................................................ 55 POTIGA TABLET .............................................................. 36 PRADAXA CAPSULE ........................................................ 50 PRAMOSONE.................................................................... 41 pravastatin tablet ............................................................ 28 prazosin capsule .............................................................. 62 PRECISION XTRA ............................................................. 43 PRED MILD DROPS .......................................................... 59 PRED-G EYE DROPS ........................................................ 59 prednicarbate cream, ointment...................................... 41 prednisolone drops ......................................................... 59 prednisone ....................................................................... 48 PREGNYL.......................................................................... 57 PREMARIN ....................................................................... 56 PREMPHASE TABLET ..................................................... 56 PREMPRO TABLET .......................................................... 56 PREPOPIK ........................................................................ 48 Prevacid ........................................................................... 50 Prevalite packet, powder ................................................ 28 previfem ........................................................................... 55 PREZCOBIX ...................................................................... 18 PREZISTA TABLET .......................................................... 18 PRIFTIN TABLET ............................................................. 16 Prilosec caps, tabs, susp .................................................. 50 PRIMAQUINE ................................................................... 16 primidone tablet .............................................................. 36 PROAIR HFA .................................................................... 60 probenecid ......................................................................... 9 probenecid/colchicine ...................................................... 9 procainamide capsule, tablet .......................................... 23 procentra solution ........................................................... 35 PROCRIT [INJ] .................................................................. 50 PROCYSBI......................................................................... 63 PROFILNINE SD ............................................................... 52

progesterone capsules.................................................... 57 PROGRAF ......................................................................... 22 PROLENSA ....................................................................... 59 PROMACTA TABLET ....................................................... 50 promethazine suppository ............................................. 47 propafenone capsule er, tablet ...................................... 23 propranolol capsule ER .................................................. 26 propranolol tablet ........................................................... 26 propranolol/HCTZ tablet ............................................... 26 Protonix ........................................................................... 50 PROTOPIC* OINTMENT.................................................. 41 protriptyline tablet ......................................................... 31 PROVENTIL HFA ............................................................. 60 PULMICORT FLEXHALER, RESPULE, TURBUHALER ... 62 PULMOZYME ................................................................... 61 PURIXAN ......................................................................... 20 pyrazinamide tablet........................................................ 16

Q

QNASL .............................................................................. 42 quasense .......................................................................... 55 quetiapine tablet ............................................................. 32 QUILLIVANT XR .............................................................. 35 quinadine gluconate tablet er ........................................ 23 quinapril tablet ............................................................... 24 quinapril/hctz tablet ...................................................... 24 quinidine sulfate tablet, tablet er ................................... 23 quinine capsule ............................................................... 16 QVAR INHALER ............................................................... 62

R

RAGWITEK ...................................................................... 62 raloxifene hcl ................................................................... 44 ramipril tablet ................................................................. 24 ranitidine capsule, syrup, tablet, vial............................. 49 RAPAFLO ......................................................................... 62 RAPAMUNE ..................................................................... 22 RAPAMUNE SOLUTION, TABLET................................... 22 RASUVO ........................................................................... 10 REBETOL ......................................................................... 21 REBIF INJECTION, REBIDOSE ........................................ 37 reclipsen .......................................................................... 55 RECOMBINATE ............................................................... 52 RELENZA DISKHALER .................................................... 17 RELION ............................................................................ 60 RELPAX .............................................................................. 9 RENAGEL* TAB ............................................................... 51 RENVELA* PACKET, TABLET ......................................... 51 reprexain tablet .............................................................. 11 REPRONEX ...................................................................... 57 RESCRIPTOR TABLET .................................................... 18 RESCULA ......................................................................... 60 reserpine tablet ............................................................... 27 RESTASIS ......................................................................... 59 RETIN-A, MICRO ............................................................. 38 REVATIO TABLET, VIAL ................................................. 29



REVLIMID CAPSULE ........................................................ 19 REYATAZ CAPSULE ......................................................... 18 RHINOCORT AQUA .......................................................... 42 ribapak dose pack ........................................................... 21 ribasphere capsule, tablet............................................... 21 RIBATAB .......................................................................... 21 ribavirin capsule, tablet .................................................. 21 RIDAURA .......................................................................... 10 rifampin capsule .............................................................. 16 rimantadine tablet .......................................................... 17 RIOMET SOLUTION ......................................................... 46 RISPERDAL CONSTA INJECTION .................................... 32 risperidone, m-tab, orally dissolving tablet, solution,

tablet ........................................................................... 32 RITALIN ........................................................................... 35 RITALIN LA ...................................................................... 35 RITALIN SR ...................................................................... 35 rivastigmine capsule ....................................................... 36 RIXUBIS ............................................................................ 52 rizatriptan .......................................................................... 9 ropinirole er tablet, tablet .............................................. 37 rosadan cream, gel .......................................................... 41 ROZEREM TABLET .......................................................... 33 RUCONEST ....................................................................... 51

S

SABRIL POWDER PACKET, TABLET .............................. 36 SAFYRAL .......................................................................... 55 SAMSCA TABLET ............................................................. 29 SANCTURA XR ................................................................. 62 SANCUSO.......................................................................... 47 SANDIMMUNE ................................................................. 22 SANDOSTATIN ................................................................. 46 SAPHRIS ........................................................................... 32 SAVELLA TABLET ........................................................... 12 selegiline capsule, tablet ................................................. 37 selfemra capsule .............................................................. 31 SELZENTRY TABLET ....................................................... 18 SEROQUEL XR TABLET ................................................... 32 SEROSTIM ........................................................................ 45 sertraline oral concentrate, tablet.................................. 31 SIGNIFOR ......................................................................... 46 SIGNIFOR LAR ................................................................. 46 sildenafil .......................................................................... 29 SILENOR ........................................................................... 33 SIMPONI ........................................................................... 10 simvastatin tablet ............................................................ 28 SIRTURO .......................................................................... 16 SMZ-TMP DS .................................................................... 15 sodium polystyrene sulfonate powder, suspension ..... 51 sodium sulfacetamide/sulfur lotion, suspension .......... 38 solia .................................................................................. 55 SONATA ........................................................................... 33 sorine tablet ..................................................................... 26 sotalol af tablet ................................................................ 26 sotalol tablet .................................................................... 26 spinosad suspension ....................................................... 40

SPIRIVA HANDIHALER ................................................... 61 spironolactone tablet ..................................................... 29 spironolactone/hydrochlorothiazide tablet ................. 29 SPORANOX SOLUTION ................................................... 15 sprintec ............................................................................ 55 SPRYCEL TABLET ........................................................... 20 sronyx .............................................................................. 55 stavudine capsule, solution ............................................ 18 STAXYN ........................................................................... 63 STELARA ......................................................................... 10 STENDRA ......................................................................... 63 STIMATE .......................................................................... 46 STIOLTO RESPIMAT ....................................................... 61 STIVARGA TABLET ......................................................... 20 STRATTERA CAPSULE .................................................... 35 STRIBILD TABLET .......................................................... 18 STROMECTOL TABLET................................................... 16 SUBLINGUAL FILM ......................................................... 35 SUBSYS ............................................................................ 11 sucralfate suspension, tablet ......................................... 48 Sulafazine DR .................................................................. 49 SULAR .............................................................................. 27 sulfadiazine tablet .......................................................... 15 sulfamethoxazole/trimethoprim ds tablet, suspension15 Sulfasalazine ................................................................... 48 sulfasalazine tablet ......................................................... 15 sulfazine tablet, ec tablet ................................................ 15 sulindac tablet ................................................................. 13 sumatriptan nasal spray ................................................... 9 sumatriptan tablet ............................................................ 9 SUMAVEL DOSEPRO ......................................................... 9 SUSTIVA CAPSULE .......................................................... 18 SUTENT CAPSULE ........................................................... 20 syeda ................................................................................ 55 SYLATRON KIT ................................................................ 19 SYMBICORT INHALER .................................................... 61 SYMLIN, SYMLINPEN [INJ] ............................................. 42 SYNAREL ......................................................................... 46 SYNRIBO .......................................................................... 20

T

diltiazem, capsule CD, ER, SA, XR ................................... 26 TABLOID TABLET ........................................................... 19 tacrolimus capsule .......................................................... 22 tacrolimus ointment ....................................................... 41 TAFINLAR........................................................................ 21 TAMIFLU GELCAP, SUSPENSION ................................... 17 tamoxifen tablet .............................................................. 23 tamsulosin capsule ......................................................... 63 TANZEUM ........................................................................ 45 TARCEVA TABLET .......................................................... 21 TARGRETIN GEL ............................................................. 39 TARGRETIN, ORAL ......................................................... 20 TASIGNA CAPSULE ......................................................... 21 TAZORAC CREAM, GEL ................................................... 40 TAZORAC GEL*, CREAM ................................................. 38 taztia capsule XT ............................................................. 27



TECFIDERA ...................................................................... 37 TECHNIVIE....................................................................... 22 TEGRETOL ....................................................................... 36 TEKAMLO ........................................................................ 25 telmisartan....................................................................... 25 temazepam capsule ......................................................... 33 TEMODAR CAPSULE ....................................................... 19 terazosin capsule ............................................................. 63 terbinafine cream, gel, spray .......................................... 39 terbinafine tablet ............................................................. 15 terbutaline nebulizer solution, tablet ............................ 60 terconazole cream, vaginal suppository ........................ 57 TESTIM............................................................................. 43 testosterone gel ............................................................... 43 testosterone vial [inj] ...................................................... 43 tetracycline capsule ........................................................ 15 TEVETEN ......................................................................... 25 TEVETEN HCT ................................................................. 25 TEV-TROPIN .................................................................... 45 thioridazine tablet ........................................................... 32 thiothixene tablet ............................................................ 32 thyroid tablet ................................................................... 47 tiagabine tablet ................................................................ 36 TIKOSYN CAPSULE .......................................................... 23 tilia fe ............................................................................... 55 timolol maleate trops ...................................................... 60 timolol tablet ................................................................... 26 tinidazole ......................................................................... 16 TIVICAY ............................................................................ 18 tizanidine capsule, tablet ................................................ 13 TOBI PODHALER ............................................................. 13 TOBRADEX OINTMENT .................................................. 58 Tobramycin inhalation solution ..................................... 13 tobramycin sulfate drops ................................................ 58 tobrymycin/dexamethasone suspension ...................... 58 tolazamide tablet ............................................................. 46 tolbutamide tablet ........................................................... 46 tolmetin capsule, tablet ................................................... 13 tolterodine la capsules .................................................... 62 tolterodine tablet ............................................................ 62 topiragen tablet ............................................................... 36 topiramate sprinkle, tablet ............................................. 36 torsemide tablet .............................................................. 29 TOVIAZ ER ....................................................................... 62 TRACLEER TABLET......................................................... 29 TRADJENTA TABLET ...................................................... 44 tramadol tablet, ER ......................................................... 11 tramadol/acetaminophen tablet .................................... 11 trandolapril tablet ........................................................... 24 trandolapril/verapamil ER ............................................. 25 Tranylcypromine tablet .................................................. 30 TRAVATAN Z* DROP ....................................................... 60 Trazodone tablet ............................................................. 30 Tretinoin 10mg capsule .................................................. 20 tretinoin gel ..................................................................... 38 TRETIN-X ......................................................................... 38 TRETTEN ......................................................................... 52 TREXALL TABLET ........................................................... 19

TREXIMET ......................................................................... 9 trezix capsule .................................................................. 11 triamcinolone cream, lotion, ointment .......................... 41 triamterene/hctz capsule, tablet ................................... 29 Triazolam ........................................................................ 33 TRIBENZOR ..................................................................... 25 TRICOR TABLET ............................................................. 28 trifluoperazine tablet ..................................................... 32 TRIGLIDE ......................................................................... 28 trihexyphenidyl elixir, tablet ......................................... 37 tri-legest fe ...................................................................... 55 tri-linyah .......................................................................... 55 TRILIPIX .......................................................................... 28 tri-lo-sprintec .................................................................. 55 trimcinolone spray ......................................................... 42 trimethobenzamide capsule, suppository..................... 48 trimipramine capsule ..................................................... 31 trinessa ............................................................................ 55 tri-previfem ..................................................................... 55 tri-sprintec ...................................................................... 55 trivora-28 ........................................................................ 55 TRIZIVIR TABLET ........................................................... 18 trospium er capsule, tablet ............................................ 62 TRUETEST/TRUETRACK ............................................... 43 TRUVADA TABLET ......................................................... 18 TUDORZA PRESSAIR ...................................................... 61 TWYNSTA ........................................................................ 25 TYKERB TABLET ............................................................ 21 TYVASO INHALATION SOLUTION ................................. 29 TYZEKA TABLET ............................................................. 21

U

UCERIS ............................................................................. 49 ULORIC .............................................................................. 9 ULTRAM ER ..................................................................... 11 ULTRESA ......................................................................... 49 unithroid tablet ............................................................... 47 ursodiol capsule, tablet .................................................. 48

V

VAGIFEM VAGINAL TABLET .......................................... 56 valacyclovir tablet........................................................... 17 VALCYTE* SOLUTION ..................................................... 17 VALCYTE*TABLET .......................................................... 17 valganciclovir hcl ............................................................ 17 valproic acid capsule, syrup ........................................... 36 valsartan/hctz tablet ...................................................... 25 vancomycin capsule........................................................ 16 vandazole vaginal gel ..................................................... 57 velivet .............................................................................. 55 VELTIN ............................................................................ 38 Venlafaxine capsule, ER tablet, tablet ............................ 31 VENTAVIS SOLUTION ..................................................... 29 VENTOLIN HFA ............................................................... 61 VERAMYST ...................................................................... 42 verapamil capsule, tablet, ER, SA ................................... 27



VESICARE ......................................................................... 62 vestura ............................................................................. 55 VFEND SUSPENSION ....................................................... 15 VIAGRA............................................................................. 63 VICTOZA ........................................................................... 45 VIDEX EC .......................................................................... 18 VIDEX SOLUTION ............................................................ 18 VIEKIRA PAK ................................................................... 22 VIMOVO............................................................................ 13 VIMPAT TABLET, SOLUTION ......................................... 36 viorele .............................................................................. 55 VIRACEPT TABLET, POWDER ........................................ 18 VIRAMUNE XR TABLET .................................................. 18 VIREAD TABLET .............................................................. 18 VITEKTA .......................................................................... 18 VIVELLE-DOT .................................................................. 56 VOGELXO ......................................................................... 43 VOLTAREN ....................................................................... 13 voriconazole suspension ................................................ 15 voriconazole tablet .......................................................... 16 VOTRIENT TABLET ......................................................... 21 VYTORIN .......................................................................... 28 VYVANSE CAPSULE ......................................................... 35

W

warfarin tablet ................................................................. 52 wera ................................................................................. 55 westhroid tablet .............................................................. 47 WILATE ............................................................................ 52 wymzya fe ........................................................................ 55

X

XALATAN ......................................................................... 60 XALKORI CAPSULE .......................................................... 21 XARELTO ......................................................................... 52 XARTEMIS XR .................................................................. 11 XELJANZ ........................................................................... 10 XELODA* TABLET ........................................................... 19 XERESE CREAM ............................................................... 40 XIFAXAN TABLET ............................................................ 16 XOPENEX HFA ................................................................. 61 XTANDI CAPSULE ............................................................ 19 XYNTHA ........................................................................... 52 XYNTHA SOLOFUSE ........................................................ 52

XYREM SOLUTION .......................................................... 33

Z

zafirlukast tablet ............................................................. 61 zaleplon capsule.............................................................. 33 ZAVESCA.......................................................................... 44 Zegerid ............................................................................. 50 ZELBORAF TABLET ........................................................ 21 ZENATANE ...................................................................... 38 zenchent .......................................................................... 55 zenchent fe ...................................................................... 55 ZENPEP ............................................................................ 49 ZENZEDI .......................................................................... 35 zeosa ................................................................................ 56 ZERIT ............................................................................... 18 ZETIA TABLET ................................................................ 28 ZETONNA ........................................................................ 42 ZIAGEN SOLUTION ......................................................... 18 ZIANA .............................................................................. 38 zidovudine capsule, syrup, tablet .................................. 18 ZIOPTAN .......................................................................... 60 ziprasidone ...................................................................... 32 ZOHYDRO ER................................................................... 11 ZOLINZA .......................................................................... 21 ZOLMITRIPAN ................................................................... 9 zolpidem ER tablet.......................................................... 33 zolpidem tablet ............................................................... 33 ZOLPIMIST ...................................................................... 33 ZOMIG NASAL SPRAY ....................................................... 9 ZOMIG TABLET ................................................................. 9 zonisamide capsule......................................................... 36 ZONTIVITY ...................................................................... 51 ZORBTIVE ........................................................................ 45 ZORTRESS TABLET ........................................................ 22 zovia 1-35e ...................................................................... 56 ZOVIRAX CREAM, OINTMENT ....................................... 40 ZUBSOLV ......................................................................... 35 ZYCLARA ......................................................................... 41 ZYDELIG .......................................................................... 21 ZYKADIA .......................................................................... 21 ZYLET .............................................................................. 59 ZYPREXA RELPREVV ...................................................... 32 ZYPREXA TABLETS, ZYDIS ............................................. 32 ZYTIGA TABLET .............................................................. 19

5-tier/open formulary plan...2016/01/01 · of our 2016 preferred drug guide. this guide provides...

Documents