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© 2018 United Healthcare Services, Inc. All rights reserved.

Preferred Drug List (PDL)Florida Healthy KidsEffective Date: 7/1/18

UnitedHealthcare Community Plan does not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to:

Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130

[email protected]

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again.

If you need help with your complaint, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, Monday through Friday, 8:00 a.m. to 8:00 p.m.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

If you need help with your complaint, please call the toll-free member phone number listed on your member ID card.

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, Monday through Friday, 8:00 a.m. to 8:00 p.m.

CSEX15MC3944283_001

UnitedHealthcare Community Plan no da un tratamiento diferente a sus miembros en base a su sexo, edad, raza, color, discapacidad o nacionalidad.

Si usted piensa que ha sido tratado injustamente por razones como su sexo, edad, raza, color, discapacidad o nacionalidad, puede enviar una queja a:

Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130

[email protected]

Usted tiene que enviar la queja dentro de los 60 días de la fecha cuando se enteró de ella. Se le enviará la decisión en un plazo de 30 días. Si no está de acuerdo con la decisión, tiene 15 días para solicitar que la consideremos de nuevo.

Si usted necesita ayuda con su queja, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, de lunes a viernes, de 8:00 a.m. a 8:00 p.m.

Usted también puede presentar una queja con el Departamento de Salud y Servicios Humanos de los Estados Unidos.

Internet: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Formas para las quejas se encuentran disponibles en: http://www.hhs.gov/ocr/office/file/index.html

Teléfono: Llamada gratuita, 1-800-368-1019, 1-800-537-7697 (TDD)

Correo: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

Si necesita ayuda para presentar su queja, por favor llame al número gratuito para miembros anotado en su tarjeta de identificación como miembro.

Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros. Tales como, cartas en otros idiomas o en letra grande. O bien, puede solicitar un intérprete. Para pedir ayuda, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, de lunes a viernes, de 8:00 a.m. a 8:00 p.m.

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INTRODUCTION UnitedHealthcare Community Plan is pleased to provide this Preferred Drug List (PDL) to be used when prescribing for patients covered by the pharmacy benefit plan offered by UnitedHealthcare Community Plan. The drugs listed in this PDL are intended to provide sufficient options to treat patients who require treatment with a drug from that pharmacologic or therapeutic class. The drugs listed in the UnitedHealthcare Community Plan PDL have been reviewed and approved by the UnitedHealthcare Community Plan Pharmacy and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare Community Plan. It is also recognized there may be occasions where an unlisted drug is desired for proper medical management of a specific patient. In those infrequent instances, the unlisted medication may be requested through the Medical prior authorization process.

The drugs represented have been reviewed by the UnitedHealthcare Community Plan Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The PDL is reflective of current medical practice as of the date of review.

This edition incorporates drugs added to the PDL since the last edition as well as numerous revisions to the prescribing information based on changes in pharmacotherapy. Comments and suggestions from practicing physicians have also been incorporated to ensure that the UnitedHealthcare Community Plan PDL is reflective of current medical practice.

NOTICE The information contained in this PDL and its appendices is provided by UnitedHealthcare Community Plan, solely for the convenience of medical providers. UnitedHealthcare Community Plan does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature.

This PDL is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs.

UnitedHealthcare Community Plan assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information.

National guidelines can be found on the Web sites listed in the Web site section or go to the National Guideline Clearinghouse site at http://www.guideline.gov.

The PDL and quarterly updates are also available on our web site at www.uhccommunityplan.com.

PREFACE The UnitedHealthcare Community Plan PDL is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state.

Products are listed by generic name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the PDL. Generics should be considered the first line of prescribing.

The UnitedHealthcare Community Plan PDL covers selected over-the-counter (OTC) products. Many are noted in the drug lists; a complete list is included on page 44. You are encouraged to prescribe OTC medications when clinically appropriate.

Preferred Drug List

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PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The UnitedHealthcare Community Plan P&T Committee includes physicians and pharmacists who are not employees or agents of UnitedHealthcare Community Plan or its affiliates. They must adhere to the Ethics Policy standards of the P&T Committee. UnitedHealthcare Community Plan medical directors and pharmacists also participate in the P&T Committee. UnitedHealthcare Community Plan’s P&T Committee meets quarterly to discuss a variety of issues. Those issues pertaining to pharmaceutical selection and pharmacy program management are communicated quarterly. This newsletter is distributed to all participating physicians who have received UnitedHealthcare Community Plan’s PDL. PDL decisions are also communicated quarterly on the UnitedHealthcare Community Plan internet site.

OUTPATIENT PRESCRIPTION DRUG BENEFIT-COVERED MEDICATIONS Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to prescribe federal legend drugs or medicines. Some items are covered only with prior authorization. Eligibility for Outpatient Prescription Drug Benefits is based on the individual member’s benefit plan.

PRODUCT SELECTION CRITERIA The UnitedHealthcare Community Plan P&T Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following:

• Safety• Efficacy• Comparison studies• Approved indications• Adverse effects• Contraindications/Warnings/Precautions• Pharmacokinetics• Patient administration/compliance considerations• Medical outcome and pharmacoeconomic

studiesWhen a new drug is considered for PDL inclusion, it will be reviewed relative to similar drugs currently included in the UnitedHealthcare Community Plan PDL. This review process may result in deletion of drug(s) in a particular therapeutic class in an effort to continually promote the most clinically useful and cost-effective agents.

All the information in the PDL is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.

PDL PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are covered on the

PDL, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are covered.

Products covered include all strengths associated with the dosage form of the cited brand name product.

carvedilol Coreg

All strengths of Coreg would be covered by this listing.

Extended-release and delayed-release products require their own entry.

diltiazem sustained release CARDIZEM SR

Dosage forms covered will be consistent with the category and use where listed.

Neomycin/polymyxin B/ Cortisporin Hydrocortisone

As listed in the OTIC section, this is limited to the otic solution and suspension. From this entry the ophthalmic solution and ointment, and the topical cream cannot be assumed to be on the list unless there are entries for these products in the OPHTHALMIC and DERMATOLOGY sections of the PDL.

When a strength or dosage form is specified, only the specified strength and dosage form is on the PDL. Other strengths/dosage forms of the reference product are not

citalopram 40 mg tabs Celexa tabs

DRUG TIERS

The drugs listed in the PDL have different tiers. The tiers are listed in the grid below.

Tier Name Drug Tier Tier 1 Generic Tier 2 Brand

GENERIC SUBSTITUTION The UnitedHealthcare Community Plan PDL requires generic substitution on the majority of products when a generic equivalent is available.

Generic substitution is a pharmacy action whereby a generic equivalent is dispensed rather than the brand name product. The PDL indicates generic availability in the “Covered Drug” column.

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If a brand name drug is medically necessary, please submit a prior authorization request.

The UnitedHealthcare Community Plan MAC list sets a ceiling price for the reimbursement of certain multisource prescription drugs. This price will typically cover the acquisition of most generics but not branded versions of the same drug. The products selected for inclusion on the MAC list are commonly prescribed and dispensed and have usually gone through the FDA’s review and approval process. An important consideration for generic substitution is the knowledge that all approvals of generic drugs by the FDA since 1984, and many generic approvals prior to 1984, have a showing of bioequivalence between the generic versions and the reference brand product. To gain FDA approval:

1. The generic drug must contain the same activeingredient(s), be the same strength and the same dosageform as the brand name product.

2. The FDA has given the generic an “A” rating comparedto the branded product indicating bioequivalence, andhas determined the generic is therapeutically equivalentto the reference brand. The ratings of generic drugs areavailable by referring to the FDA reference, ApprovedDrug Products with Therapeutic EquivalenceEvaluations (Orange Book).

When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent generic drug product is substituted for the brand name product.

There are now many brand name products that are repackaged or distributed under a generic label. The generic label version should always be considered therapeutically equivalent and substitutable for the source branded product.

DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from 1938-1962. The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled

indications, and a determination of “fully effective” was made for most of these products and they remain in the marketplace. A few DESI products remain classified as “less than fully effective” while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. UnitedHealthcare Community Plan’s PDL does not cover DESI “less than fully effective” drug products.

PLAN EXCLUSIONS The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the UnitedHealthcare Community Plan PDL.

• DESI drugs• Anti-obesity agents• Experimental / research drugs• Cosmetic drugs• Nutritional / diet supplements• Blood and blood plasma products• Agents used to promote fertility• Agents used for erectile dysfunction• Agents used for cosmetic hair growth• Drugs from manufacturers that do not participate

in the FFS Medicaid Drug Rebate Program• Diagnostic products• Medical supplies and DME except as listed:

insulin syringes, insulin needles, lancets, alcoholswabs, spacers, preferred diabetes test strips, peakflow meters (Astech, Assess, Peak Air brands,max two per year), vaporizer (limit of 1 per 3years), humidifier (limit of 1 per 3 years)

DAYS SUPPLY DISPENSING LIMITATIONS UnitedHealthcare Community Plan members mayreceive up to a one- month supply of a specificmedication per prescription order or prescriptionrefill. A medication may be reordered or refilledwhen ninety percent (90%) of the medication has been utilized for a controlled substance and eighty-fivepercent (85%) of the medication has been utilized for a non-controlled substance. If a claim is submitted before 90% of the medication has been used for a controlled substance or submitted before 85% of the medication has been used for a non-controlledsubstance, based on the original day supply submitted on the claim, the claim will reject with a “refill too soon” message. Please call the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826 with questions or for help with dosage change authorization.

MANDATORY GENERIC SUBSTITUTION The UnitedHealthcare Community Plan PDL requires mandatory generic substitution on the vast majority of products when a generic equivalent is available; however, brand name drugs may be covered in certain situations by requesting a prior authorization. The UnitedHealthcare Community Plan PDL prior authorization (PA) list does not include branded items where a generic equivalent is covered.

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PRIOR AUTHORIZATION OF NON-PDL MEDICATIONS The drugs in the UnitedHealthcare Community Plan PDL have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare Community Plan. It is also recognized that there may be occasions where an unlisted drug is desired for the proper medical management of a specific patient. In those infrequent instances, the prior authorization process reviews requests for unlisted medications the physician may consider medically necessary for patient management.

Requests for these exceptions should be made in writing by the physician and faxed or mailed to:

UnitedHealthcare Community Plan Pharmacy Services Department Fax 866-940-7328 Phone 800-310-6826

A prior authorization request form is available in the UnitedHealthcare Community Plan provider manual and should be used for all prior authorization requests if possible. Appropriate documentation must be provided to support the medical necessity of the non-PDL request. The UnitedHealthcare Community Plan Pharmacy Department will respond to all requests in accordance with state requirements.

Physicians are requested to adhere to this PDL when prescribing for patients covered by their pharmacy benefit plan offered by UnitedHealthcare Community Plan. If a pharmacist receives a prescription for a non-PDL drug, the pharmacist should contact the prescribing physician and request that the prescription be changed to a medication included in this PDL. If a PDL alternative is not appropriate the physician should then be instructed to contact the Plan for a prior authorization. Please contact the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826 with questions concerning the prior authorization process.

NON-PDL DRUGS 7-DAY AND 15-DAY OVERRIDES To ensure the use of PDL drugs, all non- PDL drugs should be discussed with the prescribing physician. If you cannot speak to the physician immediately, and there is an immediate need for the medication, the claim processing system will accept an override to permit a one-time dispensing of a 7-day supply of the newly prescribed non-PDL drug. The pharmacy should submit a claim for a 7 day supply, with a PA Type of 8 and Prior Authorization number of “00000000120”.

Please note that non-preferred drugs are available for a 7-day supply, however availability is subject to the benefit design. For assistance, pharmacies may call 800-310-6826.

Pharmacies may dispense a one-time, 15-day supply to members requiring an immediate supply of an ongoing medication. The pharmacist must contact the plan to obtain a manual 15-day override. Before the next dispensing, the pharmacy must contact the physician to discuss a PDL drug or if a prior authorization request is warranted. If the prescribing physician feels a drug is medically necessary, the physician may fax a request for prior authorization to UnitedHealthcare Community Plan at 866-940-7328, Attn: Pharmacy Department.

QUANTITY LIMITATIONS (QL) Prescriptions for monthly quantities greater than the indicated limit require a prior authorization request.

Quantity limits based on Efficient Medication Dosing The Efficient Medication Dosing Program is designed to consolidate medication dosage to the most efficient daily quantity to increase adherence to therapy and also promote the efficient use of health care dollars. The limits for the program are established based on FDA approval for dosing and the availability of the total daily dose in the least amount of tablets or capsules daily. Quantity Limits in the prescription claims processing system will limit the dispensing to consolidate dosing. The pharmacy claims processing system will prompt the pharmacist to request a new prescription order from the physician.

Controlled Substances You may fill any FOUR medications from the following classes in a 30-day period:

• benzodiazepines• sedative hypnotic agents• barbiturates• select muscle relaxants

Additional fills will require prior authorization. Medications in these classes may also be subject to individual quantity limits.

Additions to the QL program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the medical exception (prior authorization) process. Please contact the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826 with questions.

Specialty Pharmaceutical Management Program UnitedHealthcare Community Plan is continuously looking for ways to provide high quality cost effective care for Plan members. The Specialty Pharmaceutical Management Program helps UnitedHealthcare Community Plan to achieve these goals. Injectable medications that are part of this program require plan authorization and are not available through the retail pharmacy network.

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To obtain authorization, the provider must submit the appropriate Prior Authorization form to the UnitedHealthcare Community Plan Pharmacy Department via fax at 866-940-7328. The UnitedHealthcare Community Plan Pharmacy Department will review and respond to all requests in accordance with state requirements, and if authorized for payment, UnitedHealthcare Community Plan will coordinate the delivery of the product to the member or provider. Drugs that are part of this program and are on the PDL are identified in this booklet by the designation "SP". Prior Authorization request forms can be requested by calling the UnitedHealthcare Community Plan Pharmacy Department 800-310-6826.

MEDICATIONS REQUIRING DIAGNOSIS UnitedHealthcare Community Plan requires that the diagnosis for prescriptions in certain classes match the FDA-approved use or a use supported by current published evidence. Drugs in scope will list “Diagnosis required” in the Requirements and Limits section on the PDL.

The diagnosis will be verified at the point-of-sale by the pharmacy claims processing system. If a matching diagnosis is not found in the medical claim file or on the pharmacy drug claim, the prescription will be rejected at the pharmacy. The pharmacist may then contact the prescriber to verify the diagnosis and submit it on the claim.

If the diagnosis provided still does not match the approved use, prior authorization may be requested through the standard process by faxing a request to 866-940-7328.

STEP THERAPY (ST) The following PDL drugs are routinely covered only after a sufficient trial of an indicated first-line agent has been adequately tried and failed. These medications may also be requested through the Prior authorization process. While lower cost PDL alternatives may be appropriate in many instances, other non- PDL alternatives are available with prior authorization (PA).

STEP Drug First-Line Agent(s)

Amerge Trial at a minimum dose of 50mg of sumatriptan tablets.

Aricept 23mg 90 day trial of Aricept 10mg daily

Breo Ellipta 1) 30 day trial of one inhaledcorticosteroid (e.g. Arnuity Ellipta,Asmanex) OR 2) 30 day trial of a long-acting beta2- agonist (e.g. Arcapta,Striverdi) OR 30 day trial of an orallyinhaled anticholinergic agent (e.g. IncruseEllipta, Atrovent, Combivent, AnoroEllipta).

calcipotriene Trial of two topical corticosteroids cream & oint 0.005%

calcitriol Trial of two topical corticosteroids 3mcg/gm

DPP4 Inhibitors At least a 90 day trial of 1500mg/day of (Nesina, metformin. Kazano, Oseni)

Elidel

Eucrisa

fenofibrate

Minimum age of 2. Trial of one topical corticosteroid.

Trial of a topical corticosteroid AND one of the following: Elidel or tacrolimus ointment.

Fill of a statin or 90 days of gemfibrozil within the previous 180 days.

GLP-1 Agonists At least a 90 day trial of 1500mg/day of (Adlyxin, metformin. Tanzeum, Trulicity)

GLP-1/Insulin Trial of one drug from the following Combinations classes: GLP-1 or Basal Insulin (Soliqua)

Optivar 14 day trial of ketotifen within previous 90 days required first.

Ranexa Trial of one drug from the following classes: beta blockers, calcium channel blockers, long acting nitrates

Renvela 8 week trial of calcium acetate.

SGLT-2 At least a 90 day trial of 1500mg/day of Inhibitors metformin (Jardiance, Invokana, Invokamet, Invokamet XR, Synjardy, Synjardy XR)

tacrolimus 0.03% Minimum age of 2. Trial of one topical corticosteroid.

tacrolimus 0.1% Minimum age of 16. Trial of one

tolterodine

topical corticosteroid.

30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age.

tretinoin cream Trial of Differin OTC Gel 0.1%. (tretinoin cream

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0.025%, 0.05%, 0.1%, and Avita cream 0.025%)

trospium 30 day trial of oxybutynin immediate release. Step Therapy only applies to members less than 65 years of age.

Uloric 8 week trial of up to 600mg of allopurinol required first.

Vancocin One fill of metronidazole tabs or cap

Xopenex 30 day trial of Albuterol .083% or .5% Respules respules.

PDL SUGGESTIONS Providers who wish to propose PDL suggestions should forward the information to the UnitedHealthcare Community Plan Director of Pharmacy Services by either mail or fax.

Attn: Director of Pharmacy Services UnitedHealthcare Community Plan 2 Allegheny Center Suite 600 Pittsburgh, PA 15212 Fax: 866-940-7328

Providers should furnish adequate documentation, such as clinical studies from the medical literature, in order for the request to be considered for PDL addition. This literature should include information documenting clinical necessity as well as therapeutic advantages over current PDL products. Suggestions received by UnitedHealthcare Community Plan will be reviewed by the Pharmacy and Therapeutics Committee at the subsequent P&T Committee meeting.

EDITOR Your comments and suggestions regarding the UnitedHealthcare Community Plan PDL are encouraged. Your input is vital to this PDL’s continued success. All responses will be reviewed and considered. Please send your comments to:

UnitedHealthcare Community Plan Director of Pharmacy Services 2 Allegheny Center Suite 600 Pittsburgh, PA 15212 Phone: 800-310-6826 Email: [email protected] Internet: http://www.uhccommunityplan.com

LEGEND

# Only the dosage forms/strengths of the brand name products noted are on the PDL

OTC over-the-counter delayed-rel delayed-release (also known as enteric coated)

EC enteric-coated

ext-rel extended-release (also known as sustained-

release) PA Prior Authorization required QL Quantity Limits apply ST Step Therapy, see pages V-VI for details

SP Specialty Pharmaceuticals, see page V for details

NOTICE The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of UnitedHealthcare Community Plan. All rights reserved.

The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with UnitedHealthcare Community Plan. These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between UnitedHealthcare Community Plan and such third-party pharmaceutical companies.

If viewing this PDL via the Internet, please be advised that the PDL is updated periodically and changes may appear prior to their effective date to allow for notification.

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Table of Contents

Antineoplastics & Immunosuppressants . . . 4Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . 4Hormonal Antineoplastic Agents. . . . . . . . . . . . . 5Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . 6Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . 6Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Blood Modifiers - Anticoagulants . . . . . . . . . 7Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Blood Cell Formation . . . . . . . . . . . . . . . . . . . . . . 8Platelet Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . 8Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Cardiovascular Agents . . . . . . . . . . . . . . . . . . 8Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Ace Inhibitor/Diuretic Combinations. . . . . . . . . . 9Adrenolytics, Central . . . . . . . . . . . . . . . . . . . . . . . 9Alpha Blockers. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Angiotensin II Receptor Blockers (Antagonists) 9Angiotensin II Receptor Blocker Combinations 10Antiarrhythmics and Cardiac Glycosides . . . . . 10Beta Blockers and Beta Blocker/Diuretic

Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . 10Calcium Channel Blockers. . . . . . . . . . . . . . . . . 11Calcium Channel Blocker and Ace Inhibitor/

Angiotensin II Receptor Blocker Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Lipid Lowering Agents . . . . . . . . . . . . . . . . . . . . 12Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Potassium-Removing Agents . . . . . . . . . . . . . . . 13Pulmonary Arterial Hypertension . . . . . . . . . . . 13Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Central Nervous System. . . . . . . . . . . . . . . . 14Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 14Amyotrophic Lateral Sclerosis . . . . . . . . . . . . . . 15Analeptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Antidepressant . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 17Migraine Prophylactic Therapy . . . . . . . . . . . . . 18Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . 18Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . . 18Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 19Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . 21Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 22Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . 22Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 23Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Scabies and Pediculosis. . . . . . . . . . . . . . . . . . . 24Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . .26Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 28

Endocrinology . . . . . . . . . . . . . . . . . . . . . . . .28Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 28Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 29Growth Stimulating Agents. . . . . . . . . . . . . . . . . 32Lipodystropy Agents . . . . . . . . . . . . . . . . . . . . . . 32Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 32Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Gastrointestinal. . . . . . . . . . . . . . . . . . . . . . .33Constipation/Laxatives . . . . . . . . . . . . . . . . . . . . 33Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Emesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Gastroesophageal Reflux Disease (Gerd)/

Peptic Ulcers. . . . . . . . . . . . . . . . . . . . . . . . . . . 34Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . . 35Inflammatory Bowel Disease . . . . . . . . . . . . . . . 36Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 36Probiotic Supplementation. . . . . . . . . . . . . . . . . 36Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Infectious Diseases . . . . . . . . . . . . . . . . . . .37Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Antiprotozoals. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

3

Musculoskeletal . . . . . . . . . . . . . . . . . . . . . .45Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 46

OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Hormone Therapy/Menopause. . . . . . . . . . . . . 49Ovulation Stimulants . . . . . . . . . . . . . . . . . . . . . . 50Vaginal Infections. . . . . . . . . . . . . . . . . . . . . . . . . 50Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . . 51Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 51Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Immunologic Agents . . . . . . . . . . . . . . . . . . . . . . 53Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Psychiatric. . . . . . . . . . . . . . . . . . . . . . . . . . .54Alcohol Deterrents . . . . . . . . . . . . . . . . . . . . . . . . 54Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Attention Deficit Hyperactivity Disorder

(ADHD). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . 55Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . . 57Psychoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . 58Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Respiratory Drugs. . . . . . . . . . . . . . . . . . . . .59Antitussives, Decongestants, Expectorants

and Combinations . . . . . . . . . . . . . . . . . . . . . . 59Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Urological . . . . . . . . . . . . . . . . . . . . . . . . . . .66Symptomatic Benign Prostatic Hypertrophy . . 66Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Vitamins and Minerals . . . . . . . . . . . . . . . . .67Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . .80Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Antidotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Caloric Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Electrolyte Maintenance . . . . . . . . . . . . . . . . . . . 81Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 83Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 83Idiopathic Pulmonary Fibrosis (IPF) . . . . . . . . . 83Immune Thrombocytopenic Purpura . . . . . . . . 83Iron Overload . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83Irrigating Solutions. . . . . . . . . . . . . . . . . . . . . . . . 83Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . 84Medical Devices. . . . . . . . . . . . . . . . . . . . . . . . . . 84Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . . 84Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

OTC MEDICATIONS . . . . . . . . . . . . . . . . . . .87Acne. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 87Cough/Cold Allergy. . . . . . . . . . . . . . . . . . . . . . . 87Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Earwax Removal Products . . . . . . . . . . . . . . . . . 88Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 88First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 89Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Motion Sickness. . . . . . . . . . . . . . . . . . . . . . . . . . 89Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Smoking Cessation Products . . . . . . . . . . . . . . 90Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . 90Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Index of Covered Drugs . . . . . . . . . . . . . . . . 91

4

OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity Limit

ST = Step TherapySP = Specialty Pharmacy

Generic Drug Name Brand Drug Name Covered Drug Tier Requirements & Limits

Antineoplastics & Immunosuppressants

Antineoplastic AgentsAlkylating Agentsaltretamine HEXALEN brand 2busulfan MYLERAN brand 2chlorambucil LEUKERAN brand 2cyclophosphamide CYTOXAN generic 1estramustine

phosphate sodium EMCYT brand 2

lomustine GLEOSTINE brand 2melphalan ALKERAN brand 2temozolomide TEMODAR generic 1 PA, SPAntimetabolitescapecitabine XELODA generic 1 SPmercaptopurine PURINETHOL generic 1thioguanine TABLOID brand 2 QLtrifluridine/tipiracil LONSURF brand 2 PA, SPHistone Deacetylase Inhibitorspanobinostat FARYDAK brand 2 PA, SPvorinostat ZOLINZA brand 2 PA, SPKinase Inhibitorabemaciclib VERZENIO brand 2 PA, QL, SPacalabrutinib CALQUENCE brand 2 PA, QL, SPafatinib GILOTRIF brand 2 PA, SPalectinib ALECENSA brand 2 PA, SPaxitinib INLYTA brand 2 PA, SPbosutinib BOSULIF brand 2 PA, SPbrigatinib ALUNBRIG brand 2 PA, SP

cabozantinibCABOMETYXCOMETRIQ

brand 2 PA, SP

ceritinib ZYKADIA brand 2 PA, SPcobimetinib COTELLIC brand 2 PA, SPcrizotinib XALKORI brand 2 PA, SPdabrafenib TAFINLAR brand 2 PA, SPdasatinib SPRYCEL brand 2 PA, SPerlotinib TARCEVA brand 2 PA, SP

everolimusAFINITORAFINITOR DISPERZ

brand 2 PA, SP

gefitinib IRESSA brand 2 PA, SP

5




ibrutinib IMBRUVICA brand 2 PA, SPidelalisib ZYDELIG brand 2 PA, SPimatinib mesylate GLEEVEC generic 1 PA, QL, SPlapatinib ditosylate TYKERB brand 2 PA, SPlenvatinib LENVIMA brand 2 PA, SPmidostaurin RYDAPT brand 2 PA, SPnilotinib TASIGNA brand 2 PA, SPpalbociclib IBRANCE brand 2 PA, SPpazopanib VOTRIENT brand 2 PA, SPponatinib ICLUSIG brand 2 PA, SPregorafenib STIVARGA brand 2 PA, SPruxolitinib JAKAFI brand 2 PA, SPsorafenib NEXAVAR brand 2 PA, SPsunitinib SUTENT brand 2 PA, SPtrametinib MEKINIST brand 2 PA, SPvandetanib CAPRELSA brand 2 PA, SPvemurafenib ZELBORAF brand 2 PA, SPMiscellaneousleucovorin LEUCOVORIN generic 1 QL, tabs venetoclax VENCLEXTA brand 2 PA, SPProteasome Inhibitors ixazomib NINLARO brand 2 PA, SPHormonal Antineoplastic AgentsAndrogen Biosynthesis Inhibitorsabiraterone ZYTIGA brand 2 PA, QL, SPAntiandrogensbicalutamide CASODEX generic 1 QLflutamide EULEXIN generic 1 QLAntiestrogenstamoxifen NOLVADEX generic 1 QLtamoxifen citrate soln SOLTAMOX brand 2 Non-Preferred, PA, QLtoremifene FARESTON brand 2 QLAromatase Inhibitorsanastrozole ARIMIDEX generic 1 QLexemestane AROMASIN generic 1 QLletrozole FEMARA generic 1 QLGonadotropin Releasing Hormone Analogleuprolide LUPRON generic 1 PA, QL, SP

leuprolideLUPRON DEPOTLUPRON DEPOT 6-MONTH

brand 2 PA, QL, SP

6




leuprolide acetate (cpp) (3 month) kit LUPRON DEPOT-PED brand 2 Non-Preferred, PA, QL

Progestinmegestrol acetate MEGACE generic 1 QLImmunomodulatorsInterferonsinterferon alfa-2b INTRON A brand 2 PA, SPinterferon beta-1b kit BETASERON brand 2 Non-Preferred, PApeginterferon alfa-2b SYLATRON brand 2 PA, SPMiscellaneouslenalidomide caps REVLIMID brand 2 Non-Preferred, PApomalidomide POMALYST brand 2 PA, SPthalidomide THALOMID brand 2 PA, QLustekinumab sosy STELARA brand 2 Non-Preferred, PAImmunosuppressantsAntimetabolitesazathioprine IMURAN generic 1mycophenolate mofetil CELLCEPT generic 1mycophenolate mofetil HCl

solr CELLCEPT INTRAVENOUS brand 2

mycophenolate sodium MYFORTIC generic 1Calcineurin Inhibitorscyclosporine SANDIMMUNE generic 1cyclosporine inj SANDIMMUNE INJ generic 1

cyclosporine, modifiedNEORALGENGRAF

generic 1 caps, QL

cyclosporine oral solution SANDIMMUNE ORAL SOLUTION generic 1 Non-Preferred, PA

tacrolimusHECORIA PROGRAF

generic 1

Rapamycin Derivativesirolimus RAPAMUNE generic 1 tabssirolimus RAPAMUNE brand 2 solnMiscellaneouseverolimus ZORTRESS brand 2Miscellaneousalitretinoin 1% gel PANRETIN brand 2 PAbexarotene caps and

topical gel TARGRETIN brand 2 PA

7




cysteamine bitartrate CYSTAGON brand 2docetaxel soln DOCETAXEL generic 1 Non-Preferred, PAetoposide VEPESID generic 1hydroxyurea DROXIA brand 2hydroxyurea HYDREA generic 1mesna MESNEX brand 2 tabsmitotane LYSODREN brand 2niraparib ZEJULA brand 2 PA, SPoctreotide SANDOSTATIN generic 1olaparib LYNPARZA brand 2 PA, SPpasireotide SIGNIFOR brand 2 PA, SPprocarbazine MATULANE brand 2rucaparib RUBRACA brand 2 PA, SPsonidegib ODOMZO brand 2 PA, SPtopotecan HYCAMTIN brand 2 PA, SPtretinoin VESANOID generic 1 capsvismodegib ERIVEDGE brand 2 PA, SP

Blood Modifiers - Anticoagulants

Anticoagulantsapixaban ELIQUIS brand 2 QLbetrixaban BEVYXXA brand 2 QLdabigatran etexilate

mesylate caps PRADAXA brand 2 Non-Preferred, PA

dalteparin sodium soln FRAGMIN brand 2 Non-Preferred, PAedoxaban SAVAYSA brand 2 QLenoxaparin LOVENOX generic 1 QL

heparin HEPARIN generic 1INJ 5000 UNIT/ML, PF INJ 5000 UNIT/0.5ML, INJ 10000 UNIT/ML

heparin (porcine) in sodium chloride soln

HEPARIN SODIUM/NACL INJ generic 1

heparin sod (porcine) in d5w soln HEPARIN SODIUM/D5W generic 1

heparin sodium (porcine) lock flush soln HEP FLUSH-10 generic 1

rivaroxaban XARELTO brand 2 QLwarfarin COUMADIN generic 1 QL

8




Blood Cell Formationdarbepoetin alfa ARANESP brand 2 PA, SP

epoetin alfaEPOGENPROCRIT

brand 2 PA, SP

filgrastim NEUPOGEN brand 2 Non-Preferred, PA, SPfilgrastim ZARXIO brand 2 PA, SPpegfilgrastim NEULASTA brand 2 PA, SPplerixafor MOZOBIL brand 2 PA, SPsargramostim LEUKINE brand 2 PA, SPTBO-filgrastim GRANIX brand 2 Non-Preferred, PA, SPPlatelet Inhibitorsanagrelide AGRYLIN generic 1

aspirinBAYERECOTRIN

generic 1 OTC

aspirin-dipyridamole cap sr 12hr AGGRENOX brand 2 Non-Preferred, PA

cilostazol PLETAL generic 1clopidogrel PLAVIX generic 1 QLdipyridamole PERSANTINE generic 1prasugrel HCl tabs EFFIENT generic 1 Diagnosis Required, QLticagrelor BRILINTA brand 2 Diagnosis Required, QLMiscellaneousaminocaproic acid AMICAR brand 2

aminocaproic acid AMICAR generic 1 Non-Preferred, PA, 1000 mg tabs only

aminocaproic acid soln AMINOCAPROIC ACID INJ generic 1

deferasiroxEXJADEJADENU

brand 2 PA, SP

emicizumab-kxwh HEMLIBRA brand 2 PA, QL, SPpentoxifylline

extended-release TRENTAL generic 1

Cardiovascular Agents

Ace Inhibitorsbenazepril LOTENSIN generic 1captopril CAPOTEN generic 1enalapril VASOTEC generic 1

enalapril oral soln EPANED brand 2Members ≥ 8 years of age will require prior

authorization.

9




fosinopril MONOPRIL generic 1 QLlisinopril ZESTRIL generic 1 QLquinapril ACCUPRIL generic 1 QLramipril ALTACE generic 1trandolapril MAVIK generic 1Ace Inhibitor/Diuretic Combinationsbenazepril/

hydrochlorothiazide LOTENSIN HCT generic 1

captopril/ hydrochlorothiazide CAPOZIDE generic 1

enalapril/ hydrochlorothiazide VASERETIC generic 1

fosinopril/ hydrochlorothiazide MONOPRIL-HCT generic 1 QL

lisinopril/ hydrochlorothiazide ZESTORETIC generic 1 QL

quinapril/ hydrochlorothiazide ACCURETIC generic 1 QL

Adrenolytics, Centralclonidine CATAPRES generic 1clonidine HCl ptwk CATAPRES-TTS generic 1 Non-Preferred, PAguanfacine TENEX generic 1Alpha Blockersdoxazosin CARDURA generic 1prazosin MINIPRESS generic 1terazosin HYTRIN generic 1Angiotensin II Receptor Blockers (Antagonists)losartan COZAAR generic 1 QLolmesartan medoxomil

tabs BENICAR brand 2 Non-Preferred, PA

telmisartan MICARDIS brand 2 Non-Preferred, PAtelmisartan-

hydrochlorothiazide MICARDIS HCT brand 2 Non-Preferred, PA

valsartan DIOVAN brand 2 Non-Preferred, PAvalsartan-

hydrochlorothiazide DIOVAN HCT brand 2 Non-Preferred, PA

10




Angiotensin II Receptor Blocker Combinationslosartan/HCTZ HYZAAR generic 1 QLolmesartan medoxomil-

hydrochlorothiazide tab BENICAR HCT brand 2 Non-Preferred, PA

sacubitril/valsartan ENTRESTO brand 2 PA, QLAntiarrhythmics and Cardiac Glycosidesamiodarone HCl tabs PACERONE generic 1 Non-Preferred, PA,

100mg tabsamiodarone tabs CORDARONE generic 1 200 mg and 400 mgdigoxin LANOXIN generic 1disopyramide NORPACE generic 1disopyramide

extended-release NORPACE CR brand 2

dofetilide TIKOSYN generic 1 QLflecainide TAMBOCOR generic 1mexiletine MEXITIL generic 1propafenone RYTHMOL generic 1 IR only

propafenone HCl cp12 RYTHMOL SR generic 1 Non-Preferred, PA, 225mg

quinidine gluconate extended-release

QUINIDINE GLUCONATE EXT-REL generic 1

quinidine sulfate QUINIDINE SULFATE generic 1quinidine sulfate

extended-releaseQUINIDINE SULFATE

EXT-REL generic 1

sotalol BETAPACE generic 1Beta Blockers and Beta Blocker/Diuretic Combinationsacebutolol SECTRAL generic 1atenolol TENORMIN generic 1atenolol/chlorthalidone TENORETIC generic 1betaxolol KERLONE generic 1bisoprolol ZEBETA generic 1bisoprolol/

hydrochlorothiazide ZIAC generic 1

carvedilol COREG generic 1 QLlabetalol TRANDATE generic 1metoprolol LOPRESSOR generic 1 25, 50, 100mg tabletsmetoprolol &

hydrochlorothiazide tab LOPRESS HCT generic 1 Non-Preferred, PA

metoprolol succinate TOPROL XL generic 1

11




nadolol tabs NADOLOL generic 1 Non-Preferred, PApropranolol INDERAL generic 1 IR onlypropranolol HCl cp24 INDERAL LA generic 1 Diagnosis Required, QLpropranolol/HCTZ INDERIDE generic 1sotalol HCl AF BETAPACE AF generic 1Calcium Channel BlockersDihydropyridinesamlodipine NORVASC generic 1 QLfelodipine

extended-release PLENDIL generic 1 QL

nicardipine CARDENE generic 1nifedipine PROCARDIA generic 1nifedipine

extended-releaseADALAT CCPROCARDIA XL

generic 1 QL

nimodipine NIMOTOP generic 1 QLnimodipine oral soln NYMALIZE brand 2Nondihydropyridinesdiltiazem CARDIZEM generic 1diltiazem

extended-release CARDIZEM CD generic 1 QL

diltiazem HCl coated beads tb24 MATZIM LA, CARDIZEM LA brand 2 Non-Preferred, PA

diltiazem sustained-release CARDIZEM SR generic 1 QL

diltiazem extended-release

DILACOR XR TIAZAC

generic 1 QL

verapamil CALAN generic 1verapamil

extended-release CALAN SR generic 1 QL

Calcium Channel Blocker and Ace Inhibitor/Angiotensin II Receptor Blocker Combinationsamlodipine besylate-

benazepril HCl LOTREL brand 2 Non-Preferred, PA

amlodipine besylate-olmesartan medoxomil AZOR brand 2 Non-Preferred, PA

amlodipine besylate- valsartan EXFORGE generic 1 Non-Preferred, PA

amlodipine-valsartan-hydrochlorothiazide EXFORGE HCT generic 1 Non-Preferred, PA

12




Diureticsamiloride MIDAMOR generic 1amiloride/

hydrochlorothiazide MODURETIC generic 1

bumetanide BUMEX generic 1bumetanide soln BUMETANIDE INJ generic 1chlorothiazide DIURIL generic 1

chlorothiazide DIURIL ORAL SUSPENSION brand 2 QL

chlorthalidone CHLORTHALIDONE generic 1furosemide LASIX generic 1furosemide soln FUROSEMIDE INJ generic 1hydrochlorothiazide HYDROCHLOROTHIAZIDE generic 1 soln, tabshydrochlorothiazide MICROZIDE generic 1 12.5 mg capsindapamide LOZOL generic 1methyclothiazide tabs METHYCLOTHIAZIDE generic 1 Non-Preferred, PAmetolazone ZAROXOLYN generic 1spironolactone ALDACTONE generic 1spironolactone/

hydrochlorothiazide ALDACTAZIDE generic 1

torsemide DEMADEX generic 1torsemide soln DEMADEX generic 1triamterene/

hydrochlorothiazideDYAZIDEMAXZIDE

generic 1

Lipid Lowering AgentsBile Acid Resin

cholestyramine

CHOLESTYRAMINE PACKETS

CHOLESTYRAMINE LIGHT PACKETS

generic 1 Non-Preferred, PA

cholestyramineQUESTRANQUESTRAN-LIGHT

generic 1

Only the bulk products are covered (cans).

Individual packets are not covered.

colestipol HCl COLESTID generic 1 Non-Preferred, PAFibratesfenofibrate LOFIBRA generic 1 STfenofibrate micronized

caps ANTARA brand 2 Non-Preferred, PA

gemfibrozil LOPID generic 1

13




HMG-CoA Reductase Inhibitors and Combinationsatorvastatin LIPITOR generic 1 QLlovastatin MEVACOR generic 1 QLsimvastatin ZOCOR generic 1 QLLipid Lowering Agents, Otheralirocumab PRALUENT brand 2 PA, QL, SPezetimibe tabs ZETIA generic 1 PAomega-3-acid ethyl

esters caps LOVAZA generic 1 PA

Niacinsniacin NIACOR generic 1niacin extended-release NIASPAN generic 1NitratesOralisosorbide dinitrate ISORDIL generic 1isosorbide dinitrate

extended-releaseISOSORBIDE

DINITRATE ER generic 1

isosorbide mononitrate ISMO generic 1isosorbide

mononitrate extended-release

IMDUR generic 1

nitroglycerin cpcr NITROGLYCERIN ER generic 1 Non-Preferred, PASublingualisosorbide dinitrate ISORDIL S.L. generic 1nitroglycerin NITROLINGUAL generic 1nitroglycerin NITROSTAT generic 1Transdermal

nitroglycerinNITREK NITRO-DUR

generic 1 transdermal, QL

nitroglycerin NITRO-BID generic 1 ointPotassium-Removing Agentspatiromer VELTASSA brand 2 PAsodium polystyrene

sulfonate KAYEXALATE generic 1 susp only

Pulmonary Arterial Hypertensionambrisentan LETAIRIS brand 2 Diagnosis Required, SPbosentan TRACLEER brand 2 Diagnosis Required, SPmacitentan OPSUMIT brand 2 Diagnosis Required, SPriociguat ADEMPAS brand 2 Diagnosis Required, SP

14




sildenafil REVATIO generic 1 Diagnosis Required, SP, tabs

sildenafil REVATIO SUSPENSION brand 2 Diagnosis Required, SP, suspension

Miscellaneousalteplase solr CATHFLO ACTIVASE brand 2 Non-Preferred, PAdobutamine HCl soln DOBUTAMINE HCL generic 1dobutamine in d5w soln DOBUTAMINE HCL/D5W generic 1epoprostenol sodium solr FLOLAN generic 1glycine diluent for

injectionSTERILE DILUENT FOR

FLOLAN brand 2

guanabenz WYTENSIN generic 1hydralazine APRESOLINE generic 1methyldopa ALDOMET generic 1methyldopa/HCTZ ALDORIL generic 1midodrine PROAMATINE generic 1milrinone in dextrose iv

solnMILRINONE IN

DEXTROSE IV generic 1

milrinone lactate soln MILRINONE LACTATE IV generic 1minoxidil LONITEN generic 1ranolazine RANEXA brand 2 ST

sodium chloride (diagnostic aid) soln

SODIUM CHLORIDE THERMOJECT SYSTEM

brand 2 Non-Preferred, PA

sodium polystyrene sulfonate powd KIONEX generic 1 Non-Preferred, PA

Central Nervous System

Alzheimer’s Disease

donepezil ARICEPT generic 1

5 mg and 10 mg, QL, Members <18 years of age will require prior

authorization.

donepezil ARICEPT generic 123 mg, ST, Members <18 years of age will require

prior authorization.donepezil ODT ARICEPT ODT generic 1 Non-Preferred, PA

15




galantamine RAZADYNE generic 1QL, Members <18 years of age will require prior

authorization.

memantine NAMENDA generic 1QL, Members <18 years of age will require prior

authorization.

rivastigmine EXELON generic 1QL, Members <18 years of age will require prior

authorization.Amyotrophic Lateral Sclerosis (ALS)riluzole RILUTEK generic 1 QLAnalepticsarmodafinil NUVIGIL generic 1 Diagnosis Required, QLAnalgesicsBarbiturate Non-Narcotic Analgesicsbutalbital/acetaminophen PHRENILIN generic 1 QLbutalbital/acetaminophen SEDAPAP generic 1 QL

butalbital/acetaminophen/caffeine

ESGIC FIORICETZEBUTAL

generic 1 QL, 50-325-40 mg

butalbital-acetaminophen-caffeine cap FIORICET brand 2 Non-Preferred, PA,

50-300-40 mgbutalbital/aspirin/caffeine FIORINAL generic 1 QLNon-Narcotic Analgesicsacetaminophen TYLENOL generic 1 OTCaspirin/acetaminophen/

caffeine EXCEDRIN MIGRAINE generic 1 250-250-65 mg, OTC

belladonna alkaloids & opium suppos

BELLADONNA ALKALOIDS & OPIUM brand 2 Non-Preferred, PA

tramadol ULTRAM generic 1 QLNSAIDSdiclofenac potassium CATAFLAM generic 1diclofenac sodium delayed-

release VOLTAREN generic 1

diclofenac sodium delayed-release VOLTAREN XR generic 1

etodolac LODINE generic 1 IR Only

ibuprofen ADVIL generic 1 tabs, chew tabs and susp, OTC

16




ibuprofen MOTRIN generic 1 tabs, chew tabs and susp

indomethacin INDOCIN generic 1ketoprofen ORUDIS generic 1 IR onlyketorolac tromethamine TORADOL generic 1 QLketorolac tromethamine

solnKETOROLAC

TROMETHAMINE INJ generic 1

meloxicam MOBIC generic 1 QLnabumetone RELAFEN generic 1naproxen NAPROSYN generic 1

naproxen delayed release ENTERIC COATED-NAPROSYN generic 1

naproxen sodium ANAPROX generic 1 Non-Preferred, PAoxaprozin DAYPRO generic 1piroxicam FELDENE generic 1sulindac CLINORIL generic 1Opioids — Narcotic Analgesics

butalbital/apap/caff/cod FIORICET W/CODEINE generic 1 Non-Preferred, PA, 50-300-40-30 mg

butalbital/apap/caff/cod FIORICET W/CODEINE generic 1 QL, 50-325-40-30 mgbutalbital/asa/caff/cod FIORINAL W/CODEINE generic 1 QLbutorphanol STADOL generic 1 nasal spray, QLcodeine/acetaminophen TYLENOL W/CODEINE generic 1 QLcodeine sulfate generic 1 QLfentanyl transdermal DURAGESIC generic 1 PA, QLhydrocodone/

acetaminophen HYCET generic 1 Non-Preferred, PA, QL

hydrocodone/ acetaminophen

LORCETLORTABLORTAB ELIXIRNORCOVICODINVICODIN ESVICOPROFEN

generic 1 QL

hydrocodone/ acetaminophen XODOL generic 1 Non-Preferred, PA

hydrocodone/ acetaminophen soln 10-325 mg/15 ml

ZAMICET generic 1 Non-Preferred, PA, QL

17




hydrocodone ER ZOHYDRO ER brand 2 PA, QLhydrocodone/

ibuprofenIBUDONEVICOPROFEN


hydromorphone DILAUDID generic 1 QL

hydromorphone HCl soln HYDROMORPHONE HCL PF INJ generic 1

meperidine DEMEROL generic 1 QLmorphine MSIR generic 1 QLmorphine RMS generic 1 QLmorphine

extended-release MS CONTIN generic 1 PA, QL

morphine sulfate iv soln MORPHINE SULFATE IV generic 1oxycodone OXYFAST generic 1 soln, QLoxycodone ROXICODONE generic 1 tabs, QL

oxycodone HCl caps OXYIR generic 1 Non-Preferred, PA, QL capsules

oxycodone HCl tabs DAZIDOX generic 1 Non-Preferred, PAoxycodone/

acetaminophen PERCOCET generic 1 5/325 mg, 7.5/325 mg, 10/325 mg, QL

oxycodone/ acetaminophen PERCOCET generic 1 Non-Preferred, PA, QL,

2.5-325oxycodone/aspirin PERCODAN generic 1 QL

oxymorphone ER OXYMORPHONE ER generic 1 PA, QL, non-crush resistant

pentazocine/naloxone TALWIN NX generic 1 QLAntidepressantMiscellaneous Agents

trazodone HCl tabs TRAZODONE HCL generic 1 Non-Preferred, PA, 300mg tab

Goutcolchicine caps MITIGARE brand 2 Non-Preferred, PA

colchicine w/probenecid PROBENECID/ COLCHICINE generic 1 Non-Preferred, PA

Migraine Acute TherapyErgotamine Derivativesdihydroergotamine D.H.E. 45 generic 1 inj, QLergotamine/caffeine CAFERGOT generic 1ergotamine tartrate/

caffeineMIGERGOT

SUPPOSITORIES brand 2 QL

18




Selective Serotonin Agonistsnaratriptan AMERGE generic 1 STrizatriptan MAXALT/MAXALT MLT generic 1 QLsumatriptan IMITREX generic 1 QL

sumatriptan IMITREX 4 MG AND 6 MG INJ generic 1 4 mg and 6 mg inj

Migraine Prophylactic Therapyamitriptyline ELAVIL generic 1

divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1

Members ≥ 8 years of age will require prior

authorization.divalproex sodium

delayed-release DEPAKOTE generic 1 Minimum age 2

propranolol INDERAL generic 1 IR onlyverapamil CALAN generic 1Multiple Sclerosisdaclizumab ZINBRYTA brand 2 Diagnosis Required,

QL, ST, SP

dimethyl fumarate TECFIDERA brand 2 Diagnosis Required, QL, SP

fingolimod GILENYA brand 2 Diagnosis Required, QL, SP

glatiramer acetate COPAXONE generic 1 Diagnosis Required, QL, SP

glatiramer acetate GLATOPA generic 1 Diagnosis Required, QL, SP

interferon beta-1a AVONEX/AVONEX PEN, REBIF brand 2 Non-preferred, PA, QL, SP

peginterferon beta-1a PLEGRIDY brand 2 Diagnosis Required, QL, SP

teriflunomide AUBAGIO brand 2 Diagnosis Required, QL, SP

Myasthenia Gravispyridostigmine MESTINON generic 1 tabspyridostigmine MESTINON brand 2 syruppyridostigmine

extended-release MESTINON TIMESPAN generic 1

19




Parkinson’s Diseaseamantadine SYMMETREL generic 1 except tabsamantadine tablets SYMMETREL generic 1 Non-Preferred, PA, tablets benztropine COGENTIN generic 1cabergoline CABERGOLINE generic 1 Non-Preferred, PAcarbidopa & levodopa ODT PARCOPA generic 1 Non-Preferred, PAcarbidopa/levodopa SINEMET generic 1carbidopa/levodopa

extended-release SINEMET CR generic 1

carbidopa-levodopa- entacapone STALEVO generic 1 Non-Preferred, PA

entacapone COMTAN generic 1pramipexole MIRAPEX generic 1pramipexole

dihydrochloride tb24 MIRAPEX ER generic 1 Non-Preferred, PA

ropinirole REQUIP generic 1selegiline ELDEPRYL generic 1tolcapone TASMAR generic 1trihexyphenidyl ARTANE generic 1Seizurescarbamazepine TEGRETOL generic 1carbamazepine

extended-releaseCARBATROL TEGRETOL-XR

generic 1

clobazam ONFI brand 2 Diagnosis Required, QLclonazepam KLONOPIN generic 1 tabsclonazepam ODT CLONAZEPAM ODT generic 1 Non-Preferred, PAcorticotropin gel H.P. ACTHAR brand 2 Non-Preferred, PAdiazepam DIASTAT ACUDIAL generic 1 rectal gel, QL

divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1


authorization. divalproex sodium


divalproex sodium tb24 DEPAKOTE ER generic 1 Non-Preferred, PAethosuximide ZARONTIN generic 1ethotoin tabs PEGANONE brand 2 Non-Preferred, PAexogabine POTIGA brand 2 Age Limits Applyfelbamate FELBATOL generic 1 QL

20




felbamate oral susp FELBATOL ORAL SUSP generic 1QL, Members ≥ 8 years of age will require prior

authorization.gabapentin NEURONTIN generic 1 caps and tabs only

gabapentin soln NEURONTIN generic 1 Non-Preferred, PA, oral solution

lacosamide VIMPAT brand 2 Age Limits Apply, PAlacosamide soln VIMPAT brand 2 Non-Preferred, PAlamotrigine LAMICTAL generic 1 QLlamotrigine ODT LAMICTAL ODT generic 1 Non-Preferred, PA

lamotrigine chew dispersable tab LAMICTAL CD CHEW TAB generic 1


authorization.lamotrigine starter kit LAMICTAL STARTER KIT brand 2

levetiracetam KEPPRA generic 1 QL, Maximum age of 9 for solution

levetiracetam oral solution KEPPRA generic 1levetiracetam tb24 KEPPRA XR generic 1 Non-Preferred, PAmethsuximide CELONTIN brand 2

oxcarbazepine TRILEPTAL generic 1 QL, Maximum age of 9 for suspension

phenobarbital PHENOBARBITAL generic 1phenytoin DILANTIN INFATABS generic 1phenytoin sodium

extendedDILANTINPHENYTEK

generic 1

pregabalin LYRICA brand 2 PApregabalin LYRICA SOLUTION brand 2 oral solution, PAprimidone MYSOLINE generic 1rufinamide BANZEL brand 2 Diagnosis Required, QL

tiagabine GABITRIL generic 1 Age Limits Apply, PA, 2mg & 4mg

tiagabine GABITRIL brand 2 Age Limits Apply, PA, 12mg & 16mg

topiramate TOPAMAX generic 1 QL

topiramate sprinkle caps TOPAMAX SPRINKLE generic 1QL, Members ≥ 8 years of age will require prior

authorization.valproic acid DEPAKENE generic 1vigabatrin oral solution SABRIL SOLUTION brand 2 PA, SPzonisamide ZONEGRAN generic 1 QL

21




Miscellaneousguanidine HCl tabs GUANIDINE HCL brand 2 Non-Preferred, PAscopolamine pt72 TRANSDERM-SCOP brand 2 Non-Preferred, PAtetrabenazine XENAZINE generic 1 Diagnosis Required, SPvalbenazine INGREZZA brand 2 PA, QL

Dermatology

Acne VulgarisOral

isotretinoin

ABSORICAAMNESTEEMCLARAVISMYORISANZENTANE

generic 1 PA

Topical

adapalene DIFFERIN brand 2 Non-Preferred, PA, cream, lotion

adapalene gel DIFFERIN OTC GEL 0.1% generic 1azelaic acid FINACEA brand 2 gelazelaic acid (acne) AZELEX brand 2 Non-Preferred, PAbenzoyl peroxide BENZAC AC generic 1benzoyl peroxide foam BENZEFOAMULTRA generic 1 Non-Preferred, PAclindamycin CLEOCIN T generic 1 gelclindamycin CLEOCIN T generic 1 lotionclindamycin CLEOCIN T generic 1 solnerythromycin ERYGEL generic 1 gel 2% erythromycin T-STAT generic 1 soln

salicylic acid SALICYLIC ACID generic 1 Non-Preferred, PA, cream, lotion

salicylic acid NEUTROGENA OIL FREE ACNE WASH generic 1 liquid 2%, OTC

sulfacetamide/sulfur SULFACET-R generic 1 lotionsulfacetamide/sulfur PLEXION generic 1

tretinoinAVITA RETIN-A

generic 1 cream, ST

22




Bacterial Infectionsbacitracin BACITRACIN generic 1 OTCbacitracin-polymyxin-

neomycin hc oint CORTISPORIN brand 2 Non-Preferred, PA

gentamicin GENTAK generic 1mafenide acetate cream SULFAMYLON brand 2 Non-Preferred, PA

mupirocin BACTROBAN generic 1 ointment, 22 gram tube only

mupirocin calcium oint BACTROBAN NASAL brand 2 Non-Preferred, PAneomycin/polymyxin B/

bacitracin NEOSPORIN generic 1 OTC

neomycin/polymyxin-HC cream 0.5% CORTISPORIN brand 2 Non-Preferred, PA

silver nitrate soln SILVER NITRATE generic 1silver sulfadiazine SILVADENE generic 1CorticosteroidsLow Potencyalclometasone ACLOVATE generic 1 0.05% crm/oint

fluocinolone acetonide DERMA-SMOOTHE OIL/FS generic 1 oil 0.01%

fluocinolone acetonide SYNALAR generic 1 soln/crm 0.01% hydrocortisone CORTIZONE generic 1 crm, oint, lot OTChydrocortisone HYTONE generic 1 lotion 1% & 2.5%hydrocortisone HYTONE generic 1 crm 0.5%, 1%, & 2.5%hydrocortisone acetate

(rectal) suppHEMORRHOIDAL

SUP -HC 25MG generic 1 Non-Preferred, PA

hydrocortisone acetate w/pramoxine rectal cream

ANALPRAM-HC, HC PRAMOXINE generic 1 Non-Preferred, PA

hydrocortisone acetate w/pramoxine rectal foam PROCTOFOAM HC brand 2 Non-Preferred, PA

hydrocortisone (rectal) cream PROCTO-PAK generic 1 Non-Preferred, PA

hydrocortisone valerate oint WESTCORT generic 1 Non-Preferred, PA

hydrocortisone valerate crm WESTCORT generic 1 crm 0.2%

hydrocortisone/aloe CORTIZONE-10 INTENSIVE HEALING generic 1 crm 0.5% & 1%, OTC

23




Medium Potencybetamethasone val BETA-VAL generic 1 crm/oint/lotion 0.1%fluocinolone acetonide SYNALAR generic 1 crm, oint 0.025%fluticasone propionate CUTIVATE generic 1 crm 0.05%, oint 0.005%hydrocortisone butyrate LOCOID generic 1 crm/oint/soln 0.1%mometasone furoate ELOCON generic 1 crm/oint/soln 0.1%prednicarbate DERMATOP generic 1 crm 0.1%triamcinolone acetonide KENALOG generic 1 crm/lot/oint 0.025%triamcinolone acetonide KENALOG generic 1 crm/oint/lotion 0.1%High Potencybetamethasone

augmented dip DIPROLENE generic 1 lotion 0.05%

betamethasone augmented dip DIPROLENE AF generic 1 crm 0.05%

betamethasone dipropionate generic 1 crm/lotion/oint 0.05%

fluocinonide LIDEX generic 1 crm/oint/gel/soln 0.05%fluocinonide emulsified

base LIDEX E generic 1 crm 0.05%

triamcinolone acetonide KENALOG generic 1 crm 0.5%Very High Potencybetamethasone dip

augmented DIPROLENE generic 1 gel 0.05%

betamethasone dip augmented DIPROLENE generic 1 oint 0.05%

clobetasol propionate TEMOVATE generic 1 soln 0.05%

clobetasol propionate TEMOVATE generic 1 Non-Preferred, PA, crm/gel/oint 0.05%

halobetasol ULTRAVATE generic 1 cream

halobetasol propionate ULTRAVATE generic 1 Non-Preferred, PA, ointment

Fungal Infectionsciclopirox PENLAC SOLUTION 8% generic 1

ciclopirox olamine crea CICLOPIROX OLAMINE brand 2 Non-Preferred, PA, cream, suspension

clotrimazole MYCELEX generic 1clotrimazole LOTRIMIN AF generic 1 OTCclotrimazole with

betamethasone LOTRISONE generic 1

ketoconazole NIZORAL generic 1ketoconazole (topical) foam EXTINA generic 1 Non-Preferred, PA

24




miconazole DESENEX generic 1 2% OTCmiconazole MICATIN generic 1 OTCmiconazole MONISTAT-DERM generic 1miconazole nitrate

vaginal kit MICONAZOLE 1 brand 2 Non-Preferred, PA

nystatin MYCOSTATIN generic 1terbinafine LAMISIL AT generic 1 OTCtolnaftate TINACTIN generic 1 OTCPsoriasisacitretin SORIATANE generic 1 oral caps, PAcalcipotriene DOVONEX generic 1 crm/oint, STcalcipotriene DOVONEX generic 1 solncalcitriol VECTICAL generic 1 STmethoxsalen OXSORALEN-ULTRA generic 1methoxsalen (topical)

lotion OXSORALEN brand 2 Non-Preferred, PA

salicylic acid SCALPICIN generic 1 liquid 3%Rosaceabrimonidine MIRVASO brand 2 PA

metronidazoleMETROCREAMMETROGELMETROLOTION

generic 1

sulfacetamide sodium w/sulfur foam CLARIFOAM EF generic 1 Non-Preferred, PA

Scabies and Pediculosisbenzyl alcohol

(pediculicide) lotn ULESFIA brand 2 Non-Preferred, PA

crotamiton EURAX brand 2ivermectin (pediculicide)

lotn SKLICE brand 2 Non-Preferred, PA

malathion OVIDE generic 1permethrin ELIMITE generic 1 5%, QLpermethrin NIX CREME RINSE generic 1 1%, OTCpyrethrins/piperonyl

butoxide shampoo RID SHAMPOO generic 1 4% OTC

spinosad NATROBA generic 1 QLViral Infectionspenciclovir cream DENAVIR brand 2 Non-Preferred, PA

25




podofilox CONDYLOX SOL generic 1 solsalicylic acid 17%/

collodion DUOFILM generic 1 OTC

Miscellaneousaluminum acetate brand 2 soln/cream, OTCaluminum chloride topical

solution HYPERCARE 15% brand 2

ammonium lactate LAC-HYDRIN generic 1 crm 12%, lotion 5% & 12%

ammonium lactate LACTINOL generic 1 lotion 10%becaplermin gel REGRANEX brand 2 PA

benzalkonium chloride liqdREMEDY

ANTIMICROBIAL CLEANSER


calamine brand 2 lotion/ointment, OTCcollagenase oint SANTYL brand 2 QLcrisaborole EUCRISA brand 2 2% ointment, QL, STdoxepin HCl (antipruritic)

cream ZONALON generic 1 Non-Preferred, PA

fluorouracil CARAC generic 1 Non-Preferred, 0.5% cream

fluorouracil EFUDEX generic 1

hydrocortisone

PROCTOSOL HC CREAM 2.5%

PROCTOZONE CREAM-HC 2.5%

ANUSOL HC 2.5%

generic 1

hydroquinone cream LUSTRA generic 1hydroquinone soln MELQUIN 3 generic 1 Non-Preferred, PAimiquimod 5% cream ALDARA generic 1ketoconazole NIZORAL SHAMPOO generic 1 shampoo 2%lactic acid w/vitamin E

cream 10%-3500 unit/30gm

LACTIC ACID E generic 1 Non-Preferred, PA

lidocaine LIDAMANTEL generic 1 3% cream

lidocaine LIDOCAINE HCL generic 1 Non-Preferred, PA, lotion, solution

lidocaine LMX-4 generic 1 4% cream (15 gm tubes), QL

26




lidocaine XYLOCAINE generic 1 jelly 2%lidocaine XYLOCAINE generic 1 Non-Preferred, oint 5%

lidocaine/hydrocortisone acetate rectal cream kit

LIDOCAINE HCL/ HYDROCORTISONE ACETATE


lidocaine/hydrocortisone acetate rectal gel

LIDOCAINE HCL/ HYDROCORTISONE ACETATE WITH ALOE


lidocaine patch LIDODERM generic 1 Diagnosis Required, QLlidocaine/prilocaine EMLA generic 1 2.5% creamlidocaine/tetracaine cream PLIAGLIS brand 2 Non-Preferred, PA

nitroglycerin RECTIV brand 2 Diagnosis Required, QL, 0.4% rectal ointment

pimecrolimus ELIDEL brand 2cream QL, ST, not covered for members less than 2

years of age

selenium sulfide SELSUN generic 1 lotion 2.5%selenium sulfide-

pyrithione zinc in urea shampoo

SELENIUM SULFIDE generic 1 Non-Preferred, PA

tacrolimus PROTOPIC 0.03% generic 1ointment 0.03%, QL, ST; not covered for members less than 2 years of age

tacrolimus PROTOPIC 0.1% generic 1 ointment 0.1%, ST (minimum age 16)

urea 10%, urea 20%UREA 10% CREAM,

UREA 20% CREAM, UREA 10% LOTION

brand 2

urea 40% UREA 40% LOTION generic 1 lotionurea crea ALUVEA generic 1 Non-Preferred, PA

Ear, Nose & Throat

Earacetic acid VOSOL OTIC generic 1 oticacetic acid/

aluminum acetate DOMEBORO OTIC generic 1

acetic acid/ hydrocortisone VOSOL HC OTIC generic 1

27




benzocaine/antipyrine BENZOTIC generic 1carbamide peroxide DEBROX generic 1 6.5%, OTCciprofloxacin/

dexamethasone CIPRODEX brand 2 Diagnosis Required, QL

fluocinolone acetonide (otic) oil DERMOTIC OIL generic 1 Non-Preferred, PA

neomycin/polymyxin B/hydrocortisone CORTISPORIN OTIC generic 1 otic

ofloxacin FLOXIN OTIC generic 1NoseAntihistamines - First Generation, Sedating

chlorpheniramine maleate CHLOR-TRIMETON SYRUP generic 1 2 mg/5 ml, OTC

chlorpheniramine extended-release

CHLOR-TRIMETON ALLERGY generic 1 12 mg, OTC

clemastine CLEMASTINE generic 1cyproheptadine CYPROHEPTADINE generic 1diphenhydramine generic 1diphenhydramine BENADRYL generic 1 OTC

diphenhydramine HCl soln DIPHENHYDRAMINE HCL INJ generic 1

hydroxyzine HCl ATARAX generic 1hydroxyzine pamoate VISTARIL generic 1Antihistamines - Second Generation, Nonsedatingcetirizine ZYRTEC generic 1 OTC

cetirizine chew tab ZYRTEC CHEWABLE TABLET generic 1

OTC, Members ≥ 8 years of age will require prior

authorization.levocetirizine XYZAL generic 1 tabs

loratadineALAVERTCLARITIN

generic 1 OTC

Antihistamines - Others Antihistamine/Decongestant Combinationsazelastine ASTELIN generic 1 sprayazelastine HCl soln ASTEPRO generic 1 Non-Preferred, PAAntihistamine/Decongestant Combinations - First Generationchlorpheniramine/

phenylephrine/ pyrilamine

TRIOTANN generic 1

chlorpheniramine/ pseudoephedrine ACTIFED generic 1 OTC

28




Antihistamine/Decongestant Combinations - Second Generationcetirizine hydrochloride/

pseudoephedrine hydrochloride 12 hours extended-release

ZYRTEC-D generic 1 5 mg-120 mg tablet

loratadine/ pseudoephedrine extended-release

ALAVERT-DALAVERT ALRG

TAB/SINUSALLERY/CONG

generic 1 OTC

saline nasal spray 0.65% OCEAN NASAL SPRAY generic 1 OTCNasal Steroidsfluticasone FLONASE generic 1mometasone furoate

(nasal) susp NASONEX brand 2 Non-Preferred, PA

triamcinolone nasal spray NASACORT ALLERGY 24 HOUR brand 2 OTC

Miscellaneous Nasalcromolyn sodium NASALCROM generic 1 OTCipratropium nasal ATROVENT NASAL SPRAY generic 1 QLolopatadine HCl (nasal)

soln PATANASE generic 1 Non-Preferred, PA

Miscellaneous Nasal Decongestantsoxymetazoline AFRIN generic 1 OTC

phenylephrineNEO-SYNEPHRINE DIMEATAPP DRO

DECONGESgeneric 1 OTC

Throat and Mouthchlorhexidine gluconate PERIDEX generic 1lidocaine viscous XYLOCAINE generic 1pilocarpine SALAGEN generic 1triamcinolone KENALOG IN ORABASE generic 1 paste

Endocrinology

Adrenal Corticosteroidsbetamethasone sod

phosphate & acetate inj susp

CELESTONE-SOLUSPAN generic 1

cortisone acetate generic 1dexamethasone DECADRON generic 1

29




dexamethasone sodium phosphate soln

DEXAMETHASONE SODIUM PHOSPHATE generic 1

fludrocortisone FLORINEF generic 1hydrocortisone CORTEF generic 1hydrocortisone sod

succinate solr SOLU-CORTEF INJ brand 2

methylprednisolone MEDROL generic 1 4mg, 8mg, 16mg, 32mgmethylprednisolone MEDROL brand 2 2mgmethylprednisolone

acetate susp DEPO-MEDROL brand 2

methylprednisolone sod succ solr SOLU-MEDROL generic 1

pegademase bovine soln ADAGEN brand 2 Non-Preferred, PAprednisoloneprednisolone PRELONE generic 1 syrupprednisolone sodium

phosphateORAPREDPEDIAPRED

generic 1

prednisolone sodium phosphate soln

PREDNISOLONE SODIUM PHOSPHATE generic 1 Non-Preferred, PA

prednisolone sodium phosphate tbdp ORAPRED ODT brand 2 Non-Preferred, PA

prednisone DELTASONE generic 1triamcinolone acetonide

susp KENALOG-10 INJ brand 2

Androgenstestosterone cypionate DEPO-TESTOSTERONE generic 1

testosterone enanthate DELATESTRYL generic 1 Vials only. Disposable syringes not covered.

testosterone gel ANDROGEL, ANDROGEL PUMP brand 2 Non-Preferred, PA

testosterone gel topical tube, packet, and pump bottle

TESTOSTERONE 1% TOPICAL GEL generic 1 PA

Diabetes MellitusGlucose Elevating Agentsdiazoxide susp PROGLYCEM brand 2 Non-Preferred, PAglucagon HCl (diagnostic)

solrGLUCAGON HCL

DIAGNOSTIC brand 2 Non-Preferred, PA

glucagon HCL rdna (diagnostic) solr GLUCAGEN DIAGNOSTIC brand 2 Non-Preferred, PA

30




glucagon, human recombinant GLUCAGON brand 2 QL

Insulinsinsulin aspart NOVOLOG brand 2 Non-Preferred, PA, vials

insulin aspartNOVOLOG PENFILLNOVOLOG FLEXPEN


insulin aspart protamine & aspart (human) supn

NOVOLOG MIX 70/30 PREFILLED FLEXPEN brand 2 Non-Preferred, PA

insulin aspart protamine 70%/ insulin aspart 30%

NOVOLOG MIX 70/30 brand 2 QL, vials

insulin detemir LEVEMIR brand 2 Non-preferred, vialsinsulin detemir sopn LEVEMIR FLEXTOUCH brand 2 Non-Preferred, PAinsulin glargine BASAGLAR brand 2

insulin glargine LANTUS brand 2 Non-Preferred, PA, QL, vials

insulin glargine 300 unit/ml TOUJEO SOLOSTAR brand 2

insulin glargine sopn LANTUS SOLOSTAR brand 2 Non-Preferred, PAinsulin human NOVOLIN R brand 2 OTC, QL, vialsinsulin human RELION R brand 2 OTC, QL, vialsinsulin isophane HUMULIN N brand 2 OTC, QL, vialsinsulin isophane human NOVOLIN N brand 2 OTC, QL, vialsinsulin isophane human RELION N brand 2 OTC, QL, vialsinsulin isophane human

70%/regular 30% NOVOLIN 70/30 brand 2 OTC, QL, vials

insulin isophane human 70%/regular 30% RELION 70/30 brand 2 OTC, QL, vials

insulin isophane/regular HUMULIN 70/30 brand 2 OTC, QL, vialsinsulin lisopro pro/lispro HUMALOG MIX 50/50 brand 2 QL, vialsinsulin lisopro prot/lispro HUMALOG MIX 75/25 brand 2 QL, vialsinsulin lispro ADMELOG SOLOSTAR brand 2 PA, QLinsulin lispro ADMELOG VIALS brand 2insulin lispro HUMALOG brand 2 Non-Preferred, PAinsulin lispro (human) soct HUMALOG KWIKPEN brand 2 Non-Preferred, PAinsulin nph (human)

(isophane) supn HUMULIN N KWIKPEN brand 2 Non-Preferred, PA

insulin nph isophane & reg (human) supn

HUMULIN 70/30 KWIKPEN brand 2 Non-Preferred, PA

insulin regular HUMULIN R brand 2 OTC, QL, vials

31




Insulin Combinationsinsulin glargine/lixisenatide SOLIQUA brand 2 STMonitoring- Strips and Kits/Diabetic Supplies

ONE TOUCH SYSTEMS (ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC) brand 2

QL for insulin dependent or pregnant members:

allow testing up to 6 times per day

ONE TOUCH TEST STRIPS (ULTRA, VERIO) brand 2QL for non-insulin

dependent members: allow twice daily testing

Oral Agentsalogliptin NESINA generic 1 STalogliptin/metformin KAZANO generic 1 STalogliptin/pioglitazone OSENI generic 1 STacarbose PRECOSE generic 1 QLcanagliflozin INVOKANA brand 2 Non-Preferred, PAchlorpropamide DIABINESE generic 1 QLertugliflozin STEGLATRO brand 2 QL, STertugliflozin/metformin SEGLUROMET brand 2 QL, STglimepiride AMARYL generic 1 QLglipizide GLUCOTROL generic 1 QLglipizide extended-release GLUCOTROL XL generic 1 QLglipizide-metformin METAGLIP generic 1 Non-Preferred, PA, QLglyburide MICRONASE generic 1 QLglyburide, micronized GLYNASE generic 1 QLlinagliptin TRADJENTA brand 2 Non-Preferred, PA, QLmetformin GLUCOPHAGE generic 1 QLmetformin ER GLUCOPHAGE ER generic 1 QLmetformin/glyburide GLUCOVANCE generic 1 QLmetformin HCL tb24 FORTAMET brand 2 Non-Preferred, PAmiglitol GLYSET brand 2 Non-Preferred, PA, QLnateglinide STARLIX generic 1 QLpioglitazone ACTOS generic 1 QLpioglitazone/metformin ACTOPLUSMET generic 1 Non-Preferred, PA, QLrepaglinide PRANDIN generic 1 QLsaxagliptin ONGLYZA brand 2 Non-Preferred, PA, QLsitagliptin-metformin JANUMET brand 2 Non-Preferred, PA, QLsitagliptin-metformin HCL

sr 24hr JANUMET XR brand 2 Non-Preferred, PA, QL

sitagliptin phosphate JANUVIA brand 2 Non-Preferred, PA, QL

32




tolazamide TOLINASE generic 1 QLtolbutamide TOLBUTAMIDE generic 1 QLMiscellaneous Antidiabetic Agentsalbiglutide TANZEUM brand 2 STdulaglutide TRULICITY brand 2 STexenatide BYDUREON brand 2 Non-Preferred, PAexenatide pen BYDUREON brand 2 Non-Preferred, PAexenatide sopn BYETTA brand 2 Non-Preferred, PAlixisenatide ADLYXIN brand 2 STpramlintide SYMLIN brand 2 PAGrowth Stimulating Agentsmecasermin INCRELEX brand 2 PA, SP

somatropinGENOTROPINSEROSTIMSAIZEN


somatropin NUTROPIN AQ NUSPIN brand 2 PA, SPLipodystropy Agentstesamorelin EGRIFTA brand 2 Diagnosis Required, SPOsteoporosisabaloparatide inj TYMLOS brand 2 PA, SPalendronate FOSAMAX generic 1 QLcalcitonin-salmon MIACALCIN brand 2 inj, Non-Preferredcalcitonin-salmon MIACALCIN generic 1 nasal spray, QLcalcitonin-salmon FORTICAL brand 2 nasal spray, QLetidronate DIDRONEL generic 1

pamidronate disodium inj PAMIDRONATE DISODIUM generic 1

raloxifene EVISTA generic 1

zoledronic acid solnZOMETA INJRECLAST INJ

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Thyroid Diseaselevothyroxine LEVOXYL generic 1levothyroxine SYNTHROID generic 1levothyroxine sodium

solr ivLEVOTHYROXINE

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liothyronine CYTOMEL generic 1liotrix THYROLAR brand 2methimazole TAPAZOLE generic 1

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propylthiouracil PROPYLTHIOURACIL generic 1thyroid ARMOUR THYROID brand 2 Non-Preferred, PAMiscellaneousasfotase alfa STRENSIQ brand 2 PA, SPcabergoline DOSTINEX generic 1cholic acid CHOLBAM brand 2 PA, SPdesmopressin DDAVP generic 1 QLdesmopressin acetate soln STIMATE brand 2 Non-Preferred, PAmethylergonovine METHERGINE generic 1mifepristone KORLYM brand 2 PA, SP

nitisinone NITYR brand 2 Diagnosis Required, QL, SP

nitisinone ORFADIN brand 2 Non-Preferred, PApegvisomant SOMAVERT brand 2 PA, SPsapropterin KUVAN brand 2 Diagnosis Required, SP

sapropterin powder KUVAN POWDER FOR SOLUTION brand 2 Diagnosis Required, SP

taliglucerase alfa solr ELELYSO brand 2 Non-Preferred, PAuridine VISTOGARD brand 2 SPvelaglucerase alfa solr VPRIV brand 2 Non-Preferred, PA

Gastrointestinal

Constipation/Laxativescasanthranol-docusate

sodium generic 1 OTC

docusate calcium plus generic 1 OTCdocusate potasssium generic 1 OTCdocusate sodium COLACE generic 1 OTClactulose ENULOSE generic 1linaclotide LINZESS brand 2 Diagnosis Required, QLglycerin GLYCERIN SUPPOSITORY generic 1 suppository, OTC

magnesium citrate soln MAGNESIUM CITRATE SOLN generic 1

peg 3350/electrolytes COLYTE generic 1peg 3350/sodium

bicarbonate/sodium chloride

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peg 3350/sodium bicarbonate/sodium chloride/potassium chloride

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polyethylene glycol 3350 MIRALAX generic 1sennosides SENOKOT generic 1 8.6 mg tab, OTCDiarrheaalosetron HCL LOTRONEX brand 2 Non-Preferred, PAcrofelemer MYTESI brand 2 Diagnosis Required, QLdiphenoxylate/atropine LOMOTIL generic 1loperamide IMODIUM A-D generic 1 OTCloperamide LOPERAMIDE generic 1

paregoric tinc OPIUM TINCTURE (PAREGORIC) generic 1 Non-Preferred, PA

Emesisaprepitant EMEND generic 1 QL applies to 40 mg, 80

mg and 80-125 mgdronabinol MARINOL generic 1 PAdroperidol soln DROPERIDOL generic 1meclizine ANTIVERT generic 1metoclopramide REGLAN generic 1

ondansetronZOFRANZOFRAN ODT

generic 1 QL

ondansetron HCL soln ZOFRAN INJ generic 1 Non-Preferred, PAprochlorperazine COMPAZINE generic 1promethazine PHENERGAN generic 1

promethazine HCL inj soln PROMETHAZINE HCL INJ generic 1

rolapitant VARUBI brand 2trimethobenzamide TIGAN generic 1 300 mg capsGastroesophageal Reflux Disease (Gerd)/Peptic Ulcersalginic acid/sodium

bicarbonate brand 2 OTC

alumina/magnesia MAALOX generic 1 OTCalumina/magnesia/

simethicone MYLANTA generic 1 OTC

cimetidine TAGAMET generic 1clidinium &

chlordiazepoxide LIBRAX generic 1 Non-Preferred, PA

esomeprazole NEXIUM 24HR OTC brand 2 PA

35




esomeprazole granules NEXIUM DELAYED- RELEASE PACKET brand 2

Members ≥ 2 yearsof age will require prior

authorization

famotidinePEPCIDPEPCID AC

generic 1

OTC Pepcid AC 10 mg and 20 mg also covered/encouraged with written

prescription.famotidine in nacl soln FAMOTIDINE PREMIXED IV generic 1famotidine oral

suspension PEPCID brand 2 Non-Preferred, PA

famotidine soln FAMOTIDINE INJ generic 1lansoprazole PREVACID generic 1

lansoprazole delayed-release PREVACID SOLUTAB generic 1

orally disintegrating tabs, Members ≥ 2 years

of age will require priorauthorization, QL

methscopolamine bromide tabs

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omeprazole delayed-release PRILOSEC generic 1 Capsules only, QL

pantoprazole PROTONIX generic 1pantoprazole sodium pack PROTONIX PACKET brand 2 Non-Preferred, PAranitidine ZANTAC generic 1 150 mg tabsranitidine HCL soln ZANTAC INJ generic 1

ranitidine HCL tabs RANITIDINE HCL generic 1 Non-Preferred, PA, 75mg, 300mg tabs

ranitidine syrup ZANTAC generic 1sucralfate CARAFATE generic 1

sulcralfate CARAFATE SUSPENSION brand 2

suspension, Members 10 years of age up to 65 years of age will require

prior authorizationGastrointestinal Spasmdicyclomine BENTYL generic 1 tablets onlyglycopyrrolate ROBINUL generic 1hyoscyamine sulfate LEVSIN generic 1hyoscyamine sulfate

extended-release LEVSINEX generic 1

36




Inflammatory Bowel Diseasebalsalazide COLAZAL generic 1budesonide ENTOCORT EC generic 1 Diagnosis Required, QLhydrocortisone COLOCORT generic 1 enemamesalamine ROWASA generic 1 enema onlymesalamine extended-

releaseAPRISO DELZICOL

brand 2

mesalamine supp CANASA brand 2olsalazine sodium DIPENTUM brand 2sulfasalazine AZULFIDINE generic 1sulfasalazine

delayed-release AZULFIDINE EN-TABS generic 1

Pancreatic Enzymes

pancrelipaseCREONCREON 3000 UNITZENPEP

brand 2

pancrelipase (lipase- protease-amylase) cpep

PANCREAZEPERTZYEULTRESA


pancrelipase (lipase- protease-amylase) tabs VIOKACE brand 2 Non-Preferred, PA

Probiotic Supplementationacidophilus ACIDOPHILUS XTRA brand 2 OTCacidophilus ACIDOPHILUS brand 2 caps and tabs, OTC

acidophilus/bifidus ACIDOPHILUS/BIFIDUS WAFER generic 1 OTC

acidophilus/citrus pectin ACIDOPHILUS/CITRUS PECTIN generic 1 tabs, OTC

acidophilus/pectin ACIDOPHILUS/PECTIN generic 1 caps, OTC

37




probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

brand 2 OTC

Miscellaneousatropine sulfate SAL-TROPINE brand 2misoprostol CYTOTEC generic 1naloxegol MOVANTIK brand 2 Diagnosis Required, QLnatalizumab conc TYSABRI brand 2 Non-Preferred, PAteduglutide GATTEX brand 2 PA, SP

ursodiolURSO URSO FORTEACTIGALL

generic 1

Infectious Diseases

Anthelminticsalbendazole ALBENZA brand 2 PAivermectin STROMECTOL brand 2praziquantel BILTRICIDE brand 2 Diagnosis Required, QL

pyrantel pamoate PIN-X brand 2 chewable tablets, suspension

pyrantel pamoate REESE'S PINWORM MEDICINE brand 2 tablets, suspension

AntibacterialsAntituberculosis Agents aminosalicyclic acid PASER brand 2cycloserine SEROMYCIN generic 1ethambutol MYAMBUTOL generic 1

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dextrose solrCEFAZOLIN SODIUM/

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cefazolin sodium solr CEFAZOLIN SODIUM generic 1cephalexin KEFLEX generic 1 tabs are not coveredcephalexin tabs KEFLET generic 1 Non-Preferred, PACephalosporins - Second Generationcefaclor CECLOR generic 1cefotetan disodium and

dextrose solr CEFOTETAN/DEXTROSE generic 1

cefotetan disodium solr CEFOTETAN brand 2cefoxitin sodium and

dextrose solr CEFOXITIN SODIUM generic 1

cefoxitin sodium solr MEFOXIN generic 1cefprozil CEFZIL generic 1cefuroxime axetil CEFTIN brand 2 suspensioncefuroxime axetil CEFTIN generic 1 tabscefuroxime sodium solr ZINACEF generic 1Cephalosporins - Third Generationcefdinir OMNICEF generic 1cefixime SUPRAX brand 2 400 mg caps only, QLcefixime susr SUPRAX SUSPENSION generic 1 Non-Preferred, PAcefotaxime sodium solr CLAFORAN generic 1ceftazidime solr TAZICEF generic 1ceftriaxone sodium and

dextrose solrCEFTRIAXONE/

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ceftriaxone sodium solr ROCEPHIN generic 1Cephalosporins - Fourth Generationcefepime HCL solr CEFEPIME brand 2

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azithromycin pack ZITHROMAX POWDER FOR SUSP generic 1 Non-Preferred, PA

azithromycin solr ZITHROMAX IV generic 1clarithromycin BIAXIN generic 1clarithromycin ER BIAXIN XL generic 1erythromycin

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erythromycin delayed-release ERYC generic 1

erythromycin delayed-release ERY-TAB brand 2

erythromycin stearate ERYTHROCIN generic 1erythromycin/sulfisoxazole PEDIAZOLE generic 1fidaxomicin DIFICID brand 2 PAPenicillins

amoxicillin AMOXICILLIN CAPSULES AND CHEWABLES generic 1 Except 500 mg and 875

mg film-coated tabs.amoxicillin AMOXIL SUSP generic 1 suspensionamoxicillin/clavulanate AUGMENTIN generic 1amoxicillin tabs AMOXICILLIN generic 1 Non-Preferred, PAampicillin PRINCIPEN generic 1ampicillin & sulbactam

sodium for inj UNASYN generic 1

ampicillin sodium solr AMPICILLIN SODIUM INJ generic 1dicloxacillin DICLOXACILLIN generic 1penicillin g benzathine &

procaine inj BICILLIN C-R brand 2

penicillin g benzathine susp im BICILLIN L-A brand 2

penicillin g potassium solr inj PFIZERPEN-G generic 1

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penicillin g procaine susp PENICILLIN G PROCAINE brand 2penicillin g sodium solr inj PENICILLIN G SODIUM generic 1penicillin VK VEETIDS generic 1piperacillin sodium-

tazobactam sodium for inj

ZOSYN brand 2

Sulfonamidessulfadiazine SULFADIAZINE generic 1 Non-Preferred, PAsulfamethoxazole/

trimethoprim, DSBACTRIMBACTRIM DS

generic 1

Tetracyclinesdoxycycline hyclate VIBRAMYCIN, DOXY-100 generic 1 Non-Preferred, PA

doxycycline monohydrate DOXYCYCLINE MONOHYDRATE generic 1 50mg & 100mg caps

minocycline MINOCIN generic 1 capsules, except 75 mg

minocycline MINOCIN generic 1 Non-Preferred, PA, tablets, 75mg capsules

tetracycline SUMYCIN generic 1 Non-Preferred, PAMiscellaneous

colistimethate sodium solr COLISTIMETHATE SODIUM INJ generic 1

ertapenem sodium solr INVANZ INJ brand 2 Non-Preferred, PA

gentamicin in saline solnGENTAMICIN

SULFATE/0.9% SODIUM CHLORIDE

brand 2

imipenem-cilastatin intravenous for soln PRIMAXIN IV generic 1

meropenem solr MERREM brand 2polymyxin b sulfate solr POLYMYXIN B SULFATE INJ brand 2tobramycin sulfate in

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tobramycin sulfate soln TOBRAMYCIN SULFATE INJ generic 1trimethoprim HCL soln PRIMSOL generic 1 Non-Preferred, PAvancomycin HCl VANCOCIN HCL generic 1 cap, STvancomycin HCl solr inj VANCOMYCIN HCL generic 1Antifungalsanidulafungin solr ERAXIS brand 2 Non-Preferred, PAclotrimazole MYCELEX generic 1 trochesfluconazole DIFLUCAN generic 1 QL

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fluconazole in dextrose soln

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fluconazole in nacl soln FLUCONAZOLE IN NACL generic 1griseofulvin microsize GRIFULVIN V generic 1griseofulvin ultramicrosize GRIS-PEG generic 1itraconazole SPORANOX generic 1 caps, PA, QLitraconazole SPORANOX brand 2 soln, PA, QLketoconazole NIZORAL generic 1nystatin MYCOSTATIN generic 1terbinafine LAMISIL generic 1 QLtinidazole TINDAMAX brand 2 Non-Preferred, PAvoriconazole VFEND generic 1 PAAntiprotozoalsatovaquone MEPRON generic 1 PAbenznidazole BENZNIDAZOLE brand 2 PA

nitazoxanide suspension ALINIA SUSPENSION brand 2Members ≥ 8 years of age will require prior

authorization.nitazoxanide tablet ALINIA brand 2 PAmiltefosine IMPAVIDO brand 2 PApentamidine isethionate for

nebulization NEBUPENT brand 2

AntiviralsCytomegalovirus Treatmentganciclovir CYTOVENE generic 1valganciclovir VALCYTE generic 1 tabs onlyHepatitis Treatmententecavir BARACLUDE generic 1 QL

glecaprevir/pibrentasvir MAVYRET brand 2PA, SP, preferred for

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interferon alfa-2b INTRON A brand 2 PA, SPlamivudine EPIVIR HBV generic 1 QLombitas-paritapre-riton &

dasab tab pak VIEKIRA PAK brand 2 Non-Preferred, PA, QL

peginterferon alfa-2a PEGASYS brand 2 PA, QL, SPpeginterferon alfa-2a PEGASYS PROCLICK brand 2 PA, QL, SPpeginterferon alfa-2b PEG-INTRON brand 2 Non-Preferred, PA, QL

42




ribavirin REBETOL/COPEGUS generic 1 200 mg caps and tabs only, QL, SP

ribavirinRIBASPHERE RIBAPAKRIBATAB

generic 1 Non-Preferred, PA, QL

sofosbuvir/velpatasvir EPCLUSA brand 2 Non-Preferred, PA, SP

telbivudine tabs TYZEKA brand 2 Non-Preferred, PA, QLHerpes Treatmentacyclovir ZOVIRAX generic 1 caps, tabs, suspension

acyclovir topical ZOVIRAX brand 2 Non-Preferred, PA, cream, ointment

docosanol ABREVA OTC CREAM brand 2valacyclovir VALTREX generic 1Influenza Treatmentamantadine SYMMETREL generic 1 except tabs

oseltamivir TAMIFLU brand 2 Non-Preferred, suspension, QL

oseltamivir TAMIFLU generic 1 capsules, QLrimantadine FLUMADINE generic 1zanamivir RELENZA brand 2 QLIntergrase Inhibitors – Diagnosis Requireddolutegravir TIVICAY brand 2 10mg and 25mgelvitegravir VITEKTA brand 2 Non-Preferred, PAraltegravir ISENTRESS brand 2raltegravir ISENTRESS CHEWABLE brand 2 chewable tabletraltegravir ISENTRESS HD brand 2

raltegravir susp ISENTRESS SUSP brand 2Members ≥ 2 years of age will require prior

authorization.Non-Nucleoside Reverse Transcriptase Inhibitors – Diagnosis Requireddelavirdine RESCRIPTOR brand 2efavirenz SUSTIVA brand 2etravirine INTELENCE brand 2nevirapine VIRAMUNE generic 1nevirapine ER VIRAMUNE XR brand 2rilpivirine EDURANT brand 2

43




Nucleoside Analogues Nucleoside Reverse - Transcriptase Inhibitors/and Combinations – Diagnosis Required

abacavir ZIAGEN generic 1abacavir/lamivudine EPZICOM generic 1abacavir/lamivudine/

zidovudine TRIZIVIR generic 1

didanosine VIDEX brand 2didanosine

delayed-release VIDEX EC generic 1

emtricitabine EMTRIVA brand 2emtricitabine/rilpivirine/

tenofovir COMPLERA brand 2 PA

lamivudine EPIVIR generic 1lamivudine/zidovudine COMBIVIR generic 1stavudine ZERIT generic 1zidovudine RETROVIR generic 1zidovudine soln RETROVIR IV INFUSION brand 2 Non-Preferred, PANucleoside/Nucleotide Reverse-Transcriptase Inhibitor Combination – Diagnosis Requiredefavirenz/emtricitabine/

tenofovir ATRIPLA brand 2

emtricitabine/rilpivirine/tenofovir ODEFSEY brand 2

emtricitabine/tenofovir disoproxil TRUVADA brand 2

emtricitabine/tenofovir alafenamide DESCOVY brand 2 QL

Nucleotide Analogues Nucleotide Reverse - Transcriptase Inhibitor – Diagnosis Requiredtenofovir VIREAD generic 1Protease Inhibitors – Diagnosis Requiredatazanavir REYATAZ brand 2

atazanavir REYATAZ POWDER PACKET brand 2


authorizationdarunavir PREZISTA brand 2fosamprenavir LEXIVA brand 2indinavir CRIXIVAN brand 2lopinavir/ritonavir KALETRA brand 2 tabletslopinavir/ritonavir KALETRA generic 1 solutionnelfinavir VIRACEPT brand 2

44




ritonavir NORVIR brand 2saquinavir mesylate INVIRASE brand 2tipranavir APTIVUS brand 2Miscellaneous – Diagnosis Requiredabacavir/dolutegravir/

lamivudine TRIUMEQ brand 2

atazanavir sulfate- cobicistat EVOTAZ brand 2 Non-Preferred, PA

cobicistat TYBOST brand 2cobicistat/elvitegravir/

emtricitabine/tenofovir STRIBILD brand 2 PA

darunavir/cobicistat PREZCOBIX brand 2dolutegravir/rilpivirine JULUCA brand 2 QLelvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate

GENVOYA brand 2 PA

enfuvirtide FUZEON brand 2

maraviroc SELZENTRY brand 2 25 mg and 75 mg tab, solution

Miscellaneous

aztreonam in dextrose solnAZACTAM IN

ISO-OSMOTIC DEXTROSE INJ

brand 2

aztreonam solr AZACTAM INJ brand 2bedaquiline SIRTURO brand 2chloroquine phosphate ARALEN generic 1clindamycin CLEOCIN generic 1 150 mg and 300 mg onlyclindamycin CLEOCIN generic 1 Non-Preferred, PA, 75 mgclindamycin phosphate

soln CLEOCIN PHOSPHATE INJ generic 1

dapsone DAPSONE brand 2hydroxychloroquine PLAQUENIL generic 1 QLlinezolid ZYVOX generic 1 PAmaraviroc SELZENTRY brand 2mefloquine LARIAM generic 1metronidazole FLAGYL generic 1 tabs only

metronidazole in nacl soln METRONIDAZOLE IN NACL 0.79% generic 1

neomycin sulfate brand 2

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nitrofurantoin macrocrystals MACRODANTIN generic 1

nitrofurantoin susp FURADANTIN SUSP 25 MG/5 ML generic 1


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Musculoskeletal

ArthritisDisease Modifying Anti-Rheumatic Drugsadalimumab HUMIRA brand 2 PA, QL, SPanakinra KINERET brand 2 PA, QL, SPapremilast OTEZLA brand 2 PA, SPauranofin RIDAURA brand 2 QLazathioprine IMURAN generic 1 QLcanakinumab ILARIS brand 2 PA, SPcertolizumab pegol CIMZIA brand 2 PA, QL, SPetanercept ENBREL brand 2 PA, QL, SPhydroxychloroquine PLAQUENIL generic 1 QLleflunomide ARAVA generic 1 QLmethotrexate generic 1 QLpenicillamine DEPEN TITRATAB brand 2 Diagnosis Required, SPsarilumab KEVZARA brand 2 PA, SPsecukinumab COSENTYX brand 2 PA, SPsulfasalazine AZULFIDINE generic 1 QLsulfasalazine

delayed-release AZULFIDINE EN-TABS generic 1 QL

NSAIDs and Other Analgesicsacetaminophen TYLENOL generic 1 OTC

aspirinBAYERECOTRIN

generic 1 OTC

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brand 2 OTC, gel, lotion, 0.035% cream

capsaicin generic 1 OTC, 0.025%, 0.075%, & 0.1% cream

celecoxib CELEBREX generic 1 PA, QL

diclofenac 1% gel VOLTAREN 1% TOPICAL GEL generic 1 PA

diclofenac potassium CATAFLAM generic 1diclofenac sodium delayed-

release VOLTAREN generic 1

diclofenac sodium extended-release VOLTAREN XR generic 1

diclofenac w/misoprostol ARTHROTEC generic 1 Non-Preferred, PAetodolac LODINE generic 1 IR only

ibuprofen ADVIL generic 1 tabs, chew tabs and susp, OTC

ibuprofen MOTRIN generic 1 tabs, chew tabs and suspindomethacin INDOCIN generic 1ketoprofen ORUDIS generic 1 IR onlymeloxicam MOBIC generic 1 QLnaproxen NAPROSYN generic 1

naproxen delayed release ENTERIC COATED-NAPROSYN generic 1

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OB-GYN

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estradiol/ferrous fumarate

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Emergency Contraceptionlevonorgestrel PLAN B ONE STEP generic 1ulipristal acetate ELLA brand 2 Non-Preferred, PAExtended Cyclelevonorgestrel/EE SEASONALE generic 1 QLFour-Phasicestradiol valerate-

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drospirenon-ethinyl estradiol tab YAZ, YASMIN generic 1 Non-Preferred, PA

levomefolate glucosamine tabs FALESSA brand 2 Non-Preferred, PA

levonorgestrel/EE ALESSE generic 1 0.1/20, QLnorethin-eth estradiol-fe LO LOESTRIN FE brand 2 Non-Preferred, PAnorethindrone ace &

ethinyl estradiol-fe LOMEDIA 24 FE generic 1 Non-Preferred, PA

norethindrone ace-eth estradiol-fe chew tab MINASTRIN 24 FE brand 2 Non-Preferred, PA

norethindrone acetate/EE LOESTRIN 1/20 generic 1 1/20, QLnorethindrone acetate/EE/

iron LOESTRIN FE 1/20 generic 1 1/20, QL

Monophasic - 30 mcg Estrogendesogestrel/EE ORTHO-CEPT generic 1 0.15/30, QL

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levonorgestrel/EE NORDETTE generic 1 0.15/30, QLlevonorgestrel-ethinyl

estradiol AMETHYST generic 1 Non-Preferred, PA

norethindrone acetate/EE/ iron LOESTRIN FE 1.5/30 generic 1 1.5/30, QL

norethindrone acetate/EE LOESTRIN 1.5/30 generic 1 1.5/30, QLnorgestrel/EE LO/OVRAL generic 1 0.3/30, QLMonophasic - 35 mcg Estrogenethynodiol diacetate/EE ZOVIA 1/35 generic 1 1/35, QLnorethindrone & ethinyl

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norethindrone/EE TRI-NORINYL generic 1 QLnorethindrone/EE ORTHO-NOVUM 7/7/7 generic 1 QLnorgestimate/EE ORTHO TRI-CYCLEN generic 1 QLnorgestimate-eth estrad ORTHO TRI-CYCLEN LO brand 2 Non-Preferred, PAEndometriosisdanazol DANOCRINE generic 1Hormone Therapy/MenopauseEstrogens - Intramuscularestradiol valerate oil DELESTROGEN INJ brand 2Estrogens - Intravaginalestradiol ESTRADIOL brand 2estradiol vaginal ring ESTRING brand 2 Non-Preferred, PAestrogens, conjugated PREMARIN brand 2 crmyuvafem or estradiol

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Estrogens - Oralesterified estrogens MENEST brand 2 Non-Preferred, PAestradiol ESTRACE generic 1estrogens, conjugated PREMARIN brand 2estropipate OGEN generic 1Estrogens - Transdermalestradiol CLIMARA generic 1 QLestradiol patch twice

weekly VIVELLE-DOT brand 2 Non-Preferred, PA

50




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acetate ACTIVELLA generic 1 Non-Preferred, PA

estradiol-levonorgestrel td patch weekly CLIMARA PRO brand 2 Non-Preferred, PA

estradiol-norethindrone ace td patch twice weekly COMBIPATCH brand 2 Non-Preferred, PA

estrogens, conjugated/medroxyprogesterone

PREMPHASEPREMPRO

brand 2

Progestinshydroxyprogesterone

caproate oil MAKENA generic 1 Non-Preferred, PA

medroxyprogesterone acetate PROVERA generic 1

norethindrone acetate AYGESTIN generic 1progesterone micronized

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progesterone oil PROGESTERONE generic 1 Non-Preferred, PAOvulation Stimulantschoriogonadotropin alfa OVIDREL brand 2 Diagnosis Requiredchorionic gonadotropin NOVAREL brand 2 Diagnosis RequiredVaginal InfectionsOralfluconazole DIFLUCAN generic 1 QLmetronidazole FLAGYL generic 1 tabsVaginalacetic acid-oxyquinoline

vaginal gel FEM PH brand 2 Non-Preferred, PA

clindamycin CLEOCIN generic 1 crmclindamycin phosphate

vaginal supp CLEOCIN generic 1 Non-Preferred, PA, supp

clotrimazole GYNE-LOTRIMIN generic 1 OTC

metronidazoleMETROGEL-VAGINAL METROGEL 1%

generic 1

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naphazoline/glycerin CLEAR EYES REDNESS RELIEF generic 1

naphazoline HCL VASOCLEAR generic 1 soln 0.02%naphazoline/zinc sulfate VASOCLEAR A brand 2 OTColopatadine HCL soln PATADAY brand 2 Non-Preferred, PAtetrahydrozoline/

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Anti-InflammatoriesAnti-Infective/Anti-Inflammatory Combinationsgentamicin/prednisolone

acetate PRED-G brand 2

loteprednol etabonate-tobramycin ZYLET brand 2 Non-Preferred, PA

bacitracin/polymyxin/neomycin/hc CORTISPORIN generic 1 ointment

neomycin/polymyxin B/dexamethasone MAXITROL generic 1

neomycin/polymyxin B/hydrocortisone CORTISPORIN generic 1 suspension

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52




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dexamethasone (ophth) susp MAXIDEX brand 2 Non-Preferred, PA

fluorometholone FML brand 2 oint 0.1%fluorometholone FML FORTE brand 2 susp 0.25%fluorometholone FML LIQUIFILM generic 1 susp 0.1%fluorometholone acetate

opth susp FLAREX brand 2 Non-Preferred, PA

loteprednol etabonateLOTEMAXALREX


prednisolone acetate PRED FORTE generic 1 1%prednisolone acetate PRED MILD brand 2 0.12%prednisolone phosphate INFLAMASE FORTE generic 1 1%GlaucomaBeta-Blockerscarteolol generic 1levobunolol BETAGAN generic 1 ophthalmic solutionmetipranolol OPTIPRANOLOL generic 1 0.3% ophthalmic solution

metipranolol soln METIPRANOLOL OTH SOLN generic 1 Non-Preferred, PA

timolol TIMOPTIC XE generic 1 gel forming solutiontimolol maleate TIMOPTIC generic 1Carbonic Anhydrase Inhibitorsbrinzolamide-brimonidine

tartrate ophth susp SIMBRINZA brand 2 Non-Preferred, PA

brinzolamide susp AZOPT brand 2 Non-Preferred, PAdorzolamide TRUSOPT generic 1Carbonic Anhydrase Inhibitor/Beta-Blocker Combinationdorzolamide/

timolol maleate COSOPT generic 1

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timolol maleate ophth soln

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solnMOXEZAVIGAMOX


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ophthalmic solution CYSTARAN brand 2 Diagnosis Required, SP

ophthalmic irrigation solution - intraocular soln

BSS generic 1 Non-Preferred, PA

sodium chloride hypertonic MURO 128 generic 1 soln 5%

Psychiatric

Alcohol Deterrentsacamprosate CAMPRAL brand 2disulfiram ANTABUSE generic 1naltrexone REVIA generic 1AnxietyBenzodiazepinesalprazolam XANAX generic 1 QL, IR onlyalprazolam conc ALPRAZOLAM INTENSOL generic 1 Non-Preferred, PAchlordiazepoxide LIBRIUM generic 1clonazepam KLONOPIN generic 1 not wafersclorazepate TRANXENE generic 1diazepam VALIUM generic 1 QLdiazepam conc DIAZEPAM INTENSOL generic 1 Non-Preferred, PAlorazepam ATIVAN generic 1 QLlorazepam conc LORAZEPAM INTENSOL generic 1 Non-Preferred, PAlorazepam inj soln LORAZEPAM INJ generic 1oxazepam SERAX generic 1 QLMiscellaneousbuspirone BUSPAR generic 1fluvoxamine LUVOX generic 1Attention Deficit Hyperactivity Disorder (ADHD) – Diagnosis requiredamphetamine/

dextroamphetamine mixed salts

ADDERALL generic 1 QL

55




amphetamine/ dextroamphetamine mixed salts extended-release

ADDERALL XR (BRAND ADDERALL XR IS PREFERRED)

brand 2 QL

atomoxetine STRATTERA brand 2 Non-Preferreddesvenlafaxine succinate

tb24 PRISTIQ generic 1

dexmethylphenidate HCL cp24 FOCALIN XR generic 1 Non-Preferred, PA

dexmethylphenidate HCL tabs FOCALIN generic 1 Non-Preferred, PA

dextroamphetamine DEXEDRINE generic 1 Non-Preferred, PA, QLguanfacine ER INTUNIV generic 1lisdexamfetamine VYVANSE brand 2 QLlisdexamfetamine

chewable tab VYVANSE CHEWABLE brand 2 Diagnosis Required

methylphenidate RITALIN generic 1 tabs only, QLmethylphenidate

extended-release CONCERTA generic 1 Non-Preferred, PA, QL

methylphenidate extended-release

METADATE CD METADATE ER

generic 1 QL

methylphenidate extended-release RITALIN LA generic 1 Age Limit Applies, QL,

20 mg, 30 mg, 40 mg capsmethylphenidate HCL

chew METHYLIN brand 2 Non-Preferred, PA

methylphenidate HCL ER 24hr generic 1

Age Limit Applies, PA, QL, 18mg, 27mg, 36mg, 54mg tablets,

Mallinckrodt and Kremers Urban labelers

methylphenidate HCL oral susr QUILLIVANT XR brand 2 Non-Preferred, PA

methylphenidate patch DAYTRANA brand 2 Non-Preferred, PABipolar Disorderdivalproex sodium

cap sprinkle DEPAKOTE SPRINKLE generic 1Members ≥ 8 years of age will require prior

authorization.divalproex sodium


56




lithium carbonate LITHIUM CARBONATE generic 1lithium carbonate

extended-releaseESKALITH CR LITHOBID

generic 1

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fluoxetine PROZAC generic 1 10 mg and 20 mg caps and 20 mg soln only

fluoxetine HCL caps PROZAC generic 1 Non-Preferred, PA, 10 mg and 40 mg capsule

fluoxetine HCL tabs FLUOXETINE HCL generic 1 Non-Preferred, PA, tabletsfluoxetine HCL (pmdd)

caps SARAFEM brand 2 Non-Preferred, PA

paroxetine PAXIL generic 1 tabletssertraline ZOLOFT generic 1 tablets, QLSerotonin Norepinephrine Reuptake Inhibitors (SNRIs)duloxetine CYMBALTA generic 1 QLduloxetine HCL cpep IRENKA brand 2 Non-Preferred, PAvenlafaxine EFFEXOR generic 1 QLvenlafaxine XR EFFEXOR XR generic 1 QLTricyclic Antidepressants (TCAs)amitriptyline ELAVIL generic 1 tabletsamoxapine generic 1clomipramine HCL caps CLOMIPRAMINE HCL generic 1 Non-Preferred, PAdesipramine NORPRAMIN generic 1doxepin SINEQUAN generic 1imipramine HCL TOFRANIL generic 1 tabletsimipramine pamoate caps TOFRANIL-PM brand 2 Non-Preferred, PAnortriptyline PAMELOR generic 1protriptyline HCL tabs VIVACTIL brand 2 Non-Preferred, PATricyclic Antidepressant/Phenothiazine Combinationamitriptyline/perphenazine TRIAVIL generic 1

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extended-release WELLBUTRIN SR generic 1 QL

bupropion extended-release WELLBUTRIN XL generic 1 150 mg and 300 mg

maprotiline LUDIOMIL generic 1mirtazapine REMERON generic 1 tabs (not soltabs)

trazodone DESYREL generic 1 50mg, 100mg, & 150mg only

vortioxetine HBR TRINTELLIX brand 2 Non-Preferred, PAInsomniaBenzodiazepinesflurazepam DALMANE generic 1 QL

temazepam RESTORIL generic 1 15 mg and 30 mg only, QL

triazolam HALCION generic 1 QLNon-Benzodiazepineschloral hydrate CHLORAL HYDRATE generic 1diphenhydramine NYTOL QUICK CAPS generic 1 OTCdoxylamine succinate UNISOM generic 1 25mg, OTC, QLzaleplon SONATA generic 1 QLzolpidem AMBIEN generic 1 QLNarcotic Antagonistsbuprenorphine SUBUTEX generic 1 PA, QL

buprenorphine/naloxone SUBOXONE brand 2 2 mg and 8 mg film only, PA, QL

naloxone NALOXONE INJ generic 1 QLnaloxone NARCAN NASAL SPRAY brand 2naltrexone REVIA generic 1Psychoses – Diagnosis requiredAtypicals

aripiprazole ABILIFY TABLETS generic 1 Age Limit Applies, tablets, QL

aripiprazole injection ARISTADA brand 2 PA, QLaripiprazole ER injection ABILIFY MAINTENA brand 2 Age Limit Applies, PA, QL

aripiprazole ODT ABILIFY DISC TAB brand 2 Non-Preferred, PA, QL, Age Limit Applies

58




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clozapine CLOZARIL generic 125mg, 50mg, 100mg

only, Age Limit Applies, QL

clozapine CLOZARIL generic 1Non-Preferred, PA, QL,

200mg only, Age Limit Applies

clozapine ODT FAZACLO brand 2 Non-Preferred, PA

iloperidoneFANAPTFANAPT TITRATION PACK

brand 2 Non-Preferred, PA, QL

lurasidone HCL tabs LATUDA brand 2 Non-Preferred, PA, QL

olanzapine ZYPREXA generic 1 Age Limit Applies, tablets, QL

olanzapine ODT ZYPREXA ZYDIS generic 1 Non-Preferred, PA, QL, Age Limit Applies

paliperidone INVEGA SUSTENNA brand 2 Age Limit Applies, PA, QLpaliperidone INVEGA TRINZA brand 2 Age Limit Applies, PA, QLquetiapine SEROQUEL generic 1 Age Limit Applies, QL

quetiapine fumarate tb24 SEROQUEL XR generic 1 Non-Preferred, PA, QL, Age Limit Applies

risperidone RISPERDAL generic 1 Age Limit Applies, QL, (Not M-Tabs)

risperidone RISPERDAL CONSTA brand 2 Age Limit Applies, PA, QL

risperidone ODT RISPERDAL M-TAB generic 1 Non-Preferred, Age Limit Applies, PA, QL

risperidone oral soln RISPERDAL SOLUTION generic 1QL, Members ≥ 8 years of age will require prior

authorization.ziprasidone GEODON generic 1 Age Limit Applies, QLSmoking Cessationbupropion HCL (smoking

deterrent) ZYBAN generic 1 Non-Preferred, PA

nicotine NICODERM CQ generic 1 patches, QL

nicotine kitNICOTINE

TRANSDERMAL SYSTEM


nicotine polacrilex gum NICORETTE OTC generic 1 QLnicotine polacrilex lozenge COMMITT OTC generic 1 QLvarenicline CHANTIX brand 2 QL

59




Miscellaneouschlorpromazine THORAZINE generic 1

chlorpromazine HCL soln CHLORPROMAZINE HCL INJ generic 1

dextromethorphan/ quinidine NUEDEXTA brand 2 Diagnosis Required, QL

fluphenazine PROLIXIN generic 1fluphenazine decanoate PROLIXIN DECANOATE generic 1haloperidol HALDOL generic 1haloperidol decanoate HALDOL DECANOATE generic 1haloperidol lactate oral

conc HALOPERIDOL generic 1 Non-Preferred, PA

loxapine LOXITANE generic 1olanzapine-fluoxetine SYMBYAX generic 1 Non-Preferred, PAperphenazine TRILAFON generic 1pimozide ORAP generic 1thioridazine MELLARIL generic 1thiothixene NAVANE generic 1trifluoperazine STELAZINE generic 1

Respiratory DrugsAntitussives, Decongestants, Expectorants and Combinationsbenzonatate TESSALON generic 1benzonatate caps ZONATUSS brand 2 Non-Preferred, PAbrompheniramine &

phenylephrineDIMETAPP CLD ELX/

ALLERGY generic 1

brompheniramine & pseudoephedrine liquid 1-7.5 mg/ml

J-TAN D PD generic 1 Non-Preferred, PA

brompheniramine/ pseudoephedrine

ACCUHIST DROPS UNI-HIST DROPS

generic 1

brompheniramine/ pseudoephedrine/ dextromethorphan

BROMFED DM generic 1 syrup

carbinoxamine maleate PALGIC generic 1 Non-Preferred, PAcarbinoxamine maleate

extended-release KARBINAL ER brand 2 Non-Preferred, PA

chlordiazepoxide- amitriptyline LIMBITROL generic 1 Non-Preferred, PA

60




chlorphen tan/pyrilamine tan/PE tan

TRIOTANN PEDIATRIC SUSP

R-TANNAMINEgeneric 1 susp

chlorphen tan/ carbetapentane tan TUSSI-12 S generic 1 susp

chlorpheniramine & phenylephrine liquid DALLERGY, NASOHIST generic 1 Non-Preferred, PA

chlorpheniramine/ dextromethorphan

ROBITUSSIN PED LIQ CGH/COLD

ROBITUSSIN LIQ CGH/CLD

DIMETAPP SYP CGH/CLDCORICIDIN TAB

CGH/CLD

generic 1

chlorpheniramine maleate phenylephrine HCL

ED A-HIST TABLETS AND LIQUID generic 1

chlorpheniramine/ phenylephrine

RONDEC DROPSCARDEC DRO

generic 1 liquid

chlorpheniramine/ phenylephrine

RONDEC SYRUPCARDEC SYP

generic 1 syrup

chlorpheniramine/ pseudoephedrine

CPM/PSELOHIST-D

generic 1

chlorpheniramine tan/ phenylephrine tan RYNATAN PEDIATRIC SUSP generic 1 susp

chlorpheniramine w/codeine liquid LEXUSS 210 generic 1 Non-Preferred, PA

codeine-chlorcyclizine liquid POLY-TUSSIN brand 2 Non-Preferred, PA

codeine/ chlorpheniramine/pseudoephedrine

DIHISTINE DH PHENYLHIST LIQ DH

generic 1

codeine/guaifenesinGUIATUSS AC GG/CODEINE M-CLEAR WC

generic 1 QL

codeine/guaifenesin/pseudoephedrine GUIATUSS DAC generic 1

61




codeine/promethazine PROMETHAZINE W/CODEINE generic 1 QL

codeine/promethazine/phenylephrine

PROMETHAZINE VC W/CODEINE generic 1 QL

codeine- pseudoephedrine-chlorcyclizine liq

POLY-TUSSIN D brand 2 Non-Preferred, PA

codeine-pyrilamine syrup PRO-CLEAR AC brand 2 Non-Preferred, PAdextromethorphan/

brompheniramine/pseudoephedrine

BROMETANE DX generic 1

dextromethorphan- guaifenesin DURATUSS DM ELX generic 1 soln 25-225 mg/5 ml

dextromethorphan/ guaifenesin

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dextromethorphan- guaifenesin

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dextromethorphan- guaifenesin syrup

TRIAMINIC COUGH & CONGESTION CHILDRENS


dextromethorphan hbrROBITUSSIN SYP MAX-STROBITUSSIN PED SYP

generic 1 syrup

dextromethorphan polistirex extended-release

DELSYM brand 2 OTC

dextromethorphan/ promethazine

PHENERGAN DMPROMETHAZINE SYP DM

generic 1

guaifenesin ROBITUSSIN generic 1 OTC

guaifenesin ROBITUSSIN SYP CHST CNG generic 1 syrup 100 mg/5 ml

guaifenesin-codeine liquidCODAR GFMAR-COF CG

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guaifenesin extended-release MUCINEX generic 1 OTC

guaifenesin liqd YODEFAN-NF CHEST CONGESTION generic 1 Non-Preferred, PA

62




guaifenesin pack MUCINEX FOR KIDS brand 2 Non-Preferred, PAguaifenesin/

pseudoephedrineROBITUSSIN PE PSE/GG

generic 1 syrup, OTC

guaifenesin/ pseudoephedrine extended-release

MUCINEX D generic 1 OTC

guaifenesin/ pseudoephedrine/ dextromethorphan

ROBITUSSIN CF generic 1

hydrocod polst-chlorphen polst cap sr 12hr TUSSICAPS brand 2 Non-Preferred, PA

hydrocod polst-chlorphen polst cr susp

TUSSIONEX PENNKINETIC EXTENDED-RELEASE


hydrocodone/homatropine

HYCODANHYDROMET SYPHYDROCODONE/

TAB HOMATROP

generic 1

loratadine & pseudoephedrine SR 24hr

CLARITIN-D generic 1

phenylephrine-bromphen w/codeine liqd

M-END PEPOLY-TUSSIN AC


phenylephrine/ brompheniramine/ dextromethorphan

generic 1 OTC

phenylephrine- brompheniramine- dm liquid

ALAHIST DM generic 1 Non-Preferred, PA

phenylephrine-chlorphen w/codeine syrup CAPCOF brand 2 Non-Preferred, PA

phenylephrine/ chlorpheniramine/ dextromethorphan

RONDEC DM DROPSCARDEC DM DROROBITUSSIN LIQ

CGH/ALRG

generic 1 liquid

63




phenylephrine/ chlorpheniramine/ dextromethorphan

RONDEC DMSTATUSS DM SYPCARDEC DM SYPMINUTUSS DR SYP

generic 1 syrup

phenylephrine/ chlorpheniramine/ dihydrocodeine

DIHYDRO-PE SYP generic 1

phenylephrine- dexchlorphenir- codeine syrup

PRO-RED AC brand 2 Non-Preferred, PA

phenylephrine/ dextromethorphan

DIMETAPP DRO DCON/CGH generic 1

phenylephrine/ dextromethorphan/guaifenesin

ROBITUSSIN LIQ CGH/CLD generic 1

phenylephrine/ephed/CPM w/ carbetapentane

RYNATUSS PEDIATRIC SUSP generic 1 susp

phenylephrine/guaifenesin ROBITUSSIN LIQ HD/CHST generic 1

phenylephrine/pyrilamine w/hydrocodone CODIMAL DH generic 1 syrup

promethazine & phenylephrine

PROMETH VC SYP 6.25-5/5 generic 1 syrup 6.25-5 mg/ 5 mg

pseudoeph-chlorphen w/hydrocodone soln ZUTRIPRO generic 1 Non-Preferred, PA

pseudoephed- chlorphen-dm liq M-END DM LIQ generic 1 Non-Preferred, PA

pseudoephed-triprolidine-dm susp PEDIATEX TDM brand 2 Non-Preferred, PA

pseudoephedrine/ acetaminophen/ dextromethorphan

MAPAP COLD TAB generic 1

pseudoephedrine- bromphen-codeine liq

M-END WCMAR-COF BP


pseudoephedrine/ chlorpheniramine/ dextromethorphan

PEDIACARE LIQ MULTI-SY

ROBITUSSIN LIQ PED NGHT

generic 1

64




pseudoephedrine- dexbromphen-codeine liqd

M-END MAX D generic 1 Non-Preferred, PA

pseudoephedrine/ dextromethorphan/guaifenesin

MULTI SYMPTOM TAB COLD RLF generic 1

pseudoephedrine- guaifenesin cap RESPAIRE-30 brand 2 OTC, Non-Preferred, PA

pseudoephedrine/ iburprofen

CHILD IBUPRO SUS COLD

IBUOROFEN TAB COLD/SIN

generic 1

pseudoephedrine tan/ dexchlorphen tan/ DM tan

TANAFED DMX SUSPENSION

TRI-FED Xgeneric 1 susp

pseudoephedrine w/cod-gg

LORTUSS EXSUTTAR-SF


pseudoephedrine w/hydrocodone soln REZIRA generic 1 Non-Preferred, PA

pyrilamine-phenylephrine tab POLY HIST brand 2 Non-Preferred, PA

pyrilamine tan/phenyleph tan RYNA-12 S generic 1 susp

tripolidine/ pseudoephedrine

TRIPROL/PSE SYPAPHEDRID TAB

generic 1

Asthma/COPDInhalers - Beta Agonistsalbuterol sulfate VENTOLIN HFA brand 2 QLindacaterol ARCAPTA NEOHALER brand 2olodaterol STRIVERDI RESPIMAT brand 2Inhalers - Corticosteroidsbeclomethasone QVAR REDIHALER brand 2 QLfluticasone furoate ARNUITY ELLIPTA brand 2 QLfluticasone HFA FLOVENT HFA brand 2 Non-Preferred, QLfluticasone propionate FLOVENT DISKUS brand 2 Non-Preferred, QLmometasone ASMANEX TWISTHALER brand 2 QLmometasone inhalation ASMANEX HFA brand 2 QL

65




Inhalers - Corticosteroid/Beta Agonist Combinationsbudesonide/formoterol SYMBICORT brand 2 Non-Preferred

fluticasone/salmeterolADVAIR DISKUSADVAIR HFA

brand 2 Non-Preferred, QL

fluticasone/salmeterol AIRDUO RESPICLICK generic 1 QLfluticasone/vilanterol BREO ELLIPTA brand 2 STmometasone/formoterol DULERA brand 2 Non-Preferred, STInhalers - Othersipratropium/albuterol COMBIVENT RESPIMAT brand 2 inhaleripratropium HFA ATROVENT HFA brand 2tiotropium SPIRIVA brand 2 Non-Preferredtiotropium/olodaterol STIOLTO RESPIMAT brand 2 QLumeclidinium inhalation INCRUSE ELLIPTA brand 2Inhalers for Nebulization

albuterol ACCUNEB generic 1

0.63 mg/3 ml and 1.25 mg /3 ml, Covered for members less than 8

years of age. Members ≥ 8 years of age will require

prior authorization.albuterol PROVENTIL generic 1 soln 0.083%, 0.5%

budesonide PULMICORT RESPULES generic 1susp, Members ≥ 5 yearsof age will require prior

authorization, QLcromolyn INTAL generic 1 soln, QLipratropium ATROVENT generic 1 soln, QLipratropium/albuterol DUONEB generic 1 solnlevalbuterol HCl XOPENEX RESPULES generic 1 QL, STOral Agents - Beta Agonistsalbuterol sulfate tabs PROVENTIL generic 1 Non-Preferred, PA

metaproterenol METAPROTERENOL SYRUP generic 1

terbutaline BRETHINE generic 1Oral Agents - Leukotriene Modifiersmontelukast SINGULAIR generic 1 QLzafirlukast ACCOLATE brand 2 Non-Preferred, PAOral Agents - Theophyllinedyphylline tabs LUFYLLIN brand 2 Non-Preferred, PAtheophylline THEOPHYLLINE generic 1 liquid

66




theophylline extended-release THEO-24 brand 2 caps

theophylline extended-release

THEOCHRONUNIPHYL

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theophylline soln THEOPHYLLINE SOLN generic 1 Non-Preferred, PA Miscellaneousroflumilast DALIRESP brand 2 Non-Preferred, PAterbutaline sulfate inj soln TERBUTALINE SULFATE INJ generic 1

Urological

Symptomatic Benign Prostatic Hypertrophyalfuzosin ER UROXATRAL generic 1doxazosin CARDURA generic 1dutasteride caps AVODART brand 2 Non-Preferred, PAfinasteride PROSCAR generic 1tamsulosin FLOMAX generic 1terazosin HYTRIN generic 1Miscellaneousbethanechol URECHOLINE generic 1fesoterodine fumarate tb24 TOVIAZ brand 2 Non-Preferred, PAhyoscyamine,

methenamine, phenyl salicylate, sodium phosphate monobasic, methylene blue

UTIRA C brand 2

methenamine hippurateHIPREXUREX

generic 1

methenamine mandelate tabs

METHENAMINE MANDELATE generic 1 Non-Preferred, PA

neomycin/polymyxin b gu soln

NEOSPORIN GU IRRIGANT generic 1

oxybutynin chloride DITROPAN XL generic 1 QLoxybutynin IR DITROPAN generic 1

oxybutynin patch OXYTROL FOR WOMEN OTC PATCH brand 2

pentosan polysulfate sodium ELMIRON brand 2 Diagnosis Required, QL

potassium citrate UROCIT-K generic 1propantheline generic 1

67




phenazopyridine PYRIDIUM generic 1sevelamer HCl tabs RENAGEL brand 2 Non-Preferred, PAsodium citrate & citric acid

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sodium citrate/citric acid BICITRA generic 1solifenacin succinate tabs VESICARE brand 2 Non-Preferred, PAtiopronin THIOLA brand 2 Non-Preferred, PAtolterodine DETROL generic 1 STtrospium SANCTURA generic 1 ST

Vitamins and Mineralsascorbic acid soln ASCORBIC ACID INJ generic 1b-complex B-COMPLEX VITAMIN TAB generic 1 OTC, QLb-complex w/c-biotin-d-zinc

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b-complex w/c-biotin-e-minerals & folic acid

DIALYVITE 3000DIALYVITE 5000


b-complex w/c-biotin-fe & folic acid DIALYVITE 800/IRON brand 2 Non-Preferred, PA

b-complex w/c-zn & folic acid NEPHPLEX RX brand 2 Non-Preferred, PA

calcitriol ROCALTROL generic 1

calcitriol oral soln ROCALTROL SOLUTION generic 1Members ≥ 8 years of age will require prior

authorization.calcitriol soln CALCITRIOL INJ generic 1calcium OS-CAL generic 1 OTCcalcium carbonate chew CALCIUM generic 1 Non-Preferred, PAcalcium chloride

(dihydrate) soln CALCIUM CHLORIDE INJ generic 1

calcium gluconate soln CALCIUM GLUCONATE INJ generic 1carbonyl iron susp ICAR PEDIATRIC brand 2 Non-Preferred, PA

cholecalciferol BIO-D DRO-MULSION generic 1 drops 400 unit/0.03 ml, OTC

cholecalciferol BIO-D-MULSIO DRO FORTE generic 1 drops 2000 unit/0.03 ml,

OTCcholecalciferol D3-50 CAP brand 2 cap 50000 unit, OTC

cholecalciferol VITAMIN D 400 UNIT generic 1 caps & tabs 400 unit, OTC

68






chromic chloride soln CHROMIUM CHLORIDE generic 1cobalamine combination

tab FOLTRATE brand 2 Non-Preferred, PA

cupric chloride soln COPPER TRACE METAL brand 2cyanocobalamin VITAMIN B-12 generic 1 injdoxercalciferol caps HECTOROL brand 2 Non-Preferred, PAelectrolyte PEDIALYTE generic 1 soln, oral, OTCergocalciferol (D2) DRISDOL generic 1fe asp gly-fe polys-succ

acd-b cmplx-c-ca-fa tab ther pk

IROSPAN 24/6 brand 2 Non-Preferred, PA

fe asparto gly-b12-fa-c-dss-succinic acid-zn tab 75-1 mg

FERIVA 21/7 brand 2 Non-Preferred, PA

fe bisglycinate-fe polysacch-vit c-vit b12-fa cap

TARON FORTE brand 2 Non-Preferred, PA

fe carbonyl-fa-b complex-a-c-d-e-min tab 75-1.25 mg

ACTIVE FE generic 1 Non-Preferred, PA

fe carbonyl-fe gluconate-fa-vit b12-vit c-dss tab 90-1 mg

FERRALET 90 generic 1 Non-Preferred, PA

fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe)

INTEGRA F brand 2 Non-Preferred, PA

fe fum-iron poly cmplx-fa-b cmplx-c-biotin-probiotic cap

FUSION PLUS brand 2 Non-Preferred, PA

fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap

TANDEM PLUS generic 1 Non-Preferred, PA

fe fum-iron polysacch complex-fa-b complex-c-biotin cap

INTEGRA PLUS brand 2 Non-Preferred, PA

69




fe fumarate-vit c-vit b12-fa cap

HEMATOGEN FAFERROGELS FORTE


ferrous fumarate-fa-b complex-c-zn-mg-mn-cu cap

HEMOCYTE PLUS brand 2 Non-Preferred, PA

ferrous fumarate-folic acid tab HEMOCYTE-F generic 1 Non-Preferred, PA

ferrous fumarate tabs FERRIMIN 150 brand 2 Non-Preferred, PAferrous fumarate

w/fa-dss-b complex-vit c tab

NEPHRON FA brand 2 Non-Preferred, PA

ferrous gluconate tabs FERGON generic 1 Non-Preferred, PAferrous sulfate FEOSOL generic 1 OTCferrous sulfate dried tabs GNP IRON generic 1 Non-Preferred, PAferrous sulfate dried tbcr SM SLOW RELEASE IRON generic 1 Non-Preferred, PAferrous sulfate extended-

release tablets SLOW FE generic 1 Non-Preferred, PA

ferrous sulfate liquid FERROUS SULFATE generic 1 Non-Preferred, PAferrous sulfate syrup FERROUS SULFATE generic 1 Non-Preferred, PA

fluoride

GEL-KAMLURIDE LURIDE LOZI-TABSPREVIDENTPHOS-FLUR

generic 1

folic acid FOLIC ACID generic 1folic acid-b6-b12-d-

omega 3-phytosterols cap 1 mg

ANIMI-3/VITAMIN D brand 2 Non-Preferred, PA

folic acid soln FOLIC ACID INJ generic 1folic acid-vitamin b6-

vitamin b12 tab FOLGARD RX generic 1 Non-Preferred, PA

genistein-zinc amino acid chelate-vitamin d cap FOSTEUM generic 1 Non-Preferred, PA

iron combinationHEMATOGENFE PLUS PROTEIN


iron-docusate-b12-folic acid-c-e-cu-biotin tab HEMATRON-AF generic 1 Non-Preferred, PA

iron-folic acid-vit b12-vit c-docusate sod tab FERRAPLUS 90 generic 1 Non-Preferred, PA

70




iron-folic acid-vit c-vit b6-vit b12-zinc tab CORVITE 150 generic 1 Non-Preferred, PA

iron-vit c-vit b12-folic acid tab ICAR-C PLUS generic 1 Non-Preferred, PA

iron w/vitamins tabs IROMIN-G generic 1 Non-Preferred, PAl-methylfolate-

methylcobalamin- acetylcyst tab 6-2-600 mg

CEREFOLIN NAC generic 1 Non-Preferred, PA

l-methylfolate tabs L-METHYLFOLATE generic 1 Non-Preferred, PAl-methylfolate w/vit

b12-vit b6-vit b2 tab 6-1-50-5 mg

CEREFOLIN generic 1 Non-Preferred, PA

magnesium chloride inj soln

MAGNESIUM CHLORIDE INJ generic 1

manganese chloride inj soln

MANGANESE TRACE METAL INJ brand 2

magnesium oxide MAG-OX generic 1 OTCmagnesium sulfate inj soln MAGNESIUM SULFATE INJ brand 2multiple vitamin inj INFUVITE PEDIATRIC brand 2multiple vitamins

w/calcium misc ADVANCED AM/PM brand 2 Non-Preferred, PA

multiple vitamins w/minerals & calcium-folic acid tabs

FOLGARD OS brand 2 Non-Preferred, PA

multiple vitamins w/minerals & folic acid

UDAMIN SPCORVITEDIALYVITE SUPREME D


multiple vitamins w/minerals & folic acid chew

MULTICHEW CHW brand 2 Non-Preferred, PA

multivitamins/fluoride/±iron POLY-VI-FLOR generic 1

multivitamins/minerals CENTRUM generic 1 OTCniacinamide w/zinc-

copper & l-methylfolate tabs

NICOMIDE brand 2 Non-Preferred, PA

71




niacinamide w/zinc- copper-methylfolate-se-cr tabs

NICOMIDE brand 2 Non-Preferred, PA

nutritional supplements caps SENTRA AM brand 2 Non-Preferred, PA

paricalcitol caps ZEMPLAR generic 1 Non-Preferred, PAparicalcitol iv soln ZEMPLAR IV brand 2ped multivitamins

w/fl & iron liqd ESCAVITE LQ brand 2 Non-Preferred, PA

ped multivitamins w/fl & iron susp POLY-VI-FLOR/IRON brand 2 Non-Preferred, PA

pediatric multiple vitamin w/minerals & c soln VITAMAX PEDIATRIC brand 2 Non-Preferred, PA

pediatric multivitamins w/fl POLY-VI-FLOR brand 2 Non-Preferred, PA, chew,

suspension

pediatric multivitamins w/fl & iron chew

ESCAVITE DESCAVITEPOLY-VI-FLOR/IRON


pediatric vitamins acd & l-methylfolate w/fluoride susp

TRI-VI-FLOR brand 2 Non-Preferred, PA

phytonadione MEPHYTON brand 2phytonadione soln VITAMIN K1 generic 1polysacch fe cmplx-fe

heme poly-fa-b12 tab HEMETAB brand 2 Non-Preferred, PA

polysaccharide iron complex

NOVAFERRUM 50NOVAFERRUM

PEDIATRIC DROPSbrand 2 Non-Preferred, PA, caps,

liquid

pot & sod citrates w/citric ac

TRICITRATESCYTRA-3


prenat-FE Bis-FE prot succ-FA-CA & omega 3

COMPLETE NATALCARE PAK DHA brand 2


PRUET DHA PAK SETONET PAK brand 2


TRUST NATALCARE PAK DHA brand 2

72




prenat-FE bis-FE prot succ-FA-CA & omega DR

PRUET DHAEC PAK brand 2

prenat vit w/iron carbonyl-fe asp glyc-fa-omega fatty acid

OB COMPLETE/DHA brand 2 Non-Preferred, PA

prenat w/o A w/fecbn-fegl-DSS-FA & DHA

FOLTABS PAK PLUS DHA RE OB + DHA PAK brand 2

prenatal multivitamins & minerals w/l-methylfolate-fa chew

PRENATE CHEW brand 2 Non-Preferred, PA

prenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega 3 m

PR NATAL 400 generic 1 Non-Preferred, PA

prenatal mv & min w/fe carbonyl-docusate-folic acid-dha tab

PREQUE 10 brand 2 Non-Preferred, PA

prenatal mv & min w/fe fumarate-fa-dha misc

GESTICARE PAK DHACENTRUM SPECIALIST

PRENATALSIMILAC PRENATAL EARLY

SHIELDTHERANATAL COMPLETETHERANATAL PLUSENFAMIL EXPECTAVITAFOL-OB+DHAPNV-OB/DHA


prenatal mv & min w/fe polysaccharide complex-fa-dha

VITAFOL-ONESELECT-OB+DHAPNV-FIRST SOFTGELCHOICE-OB + DHA

COMBO PACK


73




prenatal mv & min w/o vit a w/fe polysac cmplx-fa-ca-omega

NESTABS ABC brand 2 Non-Preferred, PA

prenatal vit w/FE bisglycinate chelate-FA

VINATE II brand 2


GENTEX ADE 28-1 MG brand 2


VINATE AZ EX brand 2

prenatal vit w/fe carbonyl-fe bisglycinate-fa-fish oil cap

PNV-TOTAL brand 2 Non-Preferred, PA

prenatal vit w/fe fum-iron polysacch complex- fa-omega 3

SE-TAN DHATARON-C DHACONCEPT DHAVIRT-C DHA


prenatal vit w/fe glycine cysteinate-fa-omega 3 fatty acid

ENBRACE HR brand 2 Non-Preferred, PA

prenatal vit w/fe poly cmplx-fe heme polypept-fa & omega 3

HEMENATAL OB + DHA brand 2 Non-Preferred, PA

prenatal vit w/fe polysacch cmplx-fe asp-fe glyc-fa & dha

PAIRE OB brand 2 Non-Preferred, PA

prenatal vit w/fe polysacch cmplx-fe heme polypept-fa & dha

VP-HEME ONEPREFERAOB +DHA


prenatal vit w/fe polysacch complex-fe heme polypeptide-fa

PREFERA OBHEMNATAL OBVP-HEME-OBVP-ERA OB


74




prenatal vit w/fe polysacch complex-l methylfolate-fa-dha

VITAFOL ULTRA brand 2 Non-Preferred, PA

prenatal vit w/ferrous fumarate-fa-omega 3 fatty acids

VIVA DHAVP-PNV-DHAC-NATE DHARELNATE DHA


prenatal vit w/ferrous fumarate-folic acid tabs NATALVIT brand 2 Non-Preferred, PA

prenatal vit w/ferrous fumarate-l methylfolate-folic acid

TL FOLATEPNV-SELECTZATEAN-PNVIRT-PN


prenatal vit w/FE polysac cmplx-FA EDGE OB CHW brand 2

prenatal vit w iron carbonyl-FA ATABEX PRENATAL brand 2

prenatal vit w/iron carbonyl-fe aspart glyc-fa-omega 3 cap

ULTIMATECARE ONEFOLCAPS OMEGA-3

CAPSULEbrand 2 Non-Preferred, PA

prenatal vit w/iron carbonyl-fe aspart glycinate-fa tabs

OB COMPLETE PREMIER brand 2 Non-Preferred, PA

prenatal vit w/iron carbonyl-folic acid tabs OB COMPLETE brand 2 Non-Preferred, PA

prenatal vit w/iron polysaccharide cmplx-l methylfolate-fa

SELECT-OB brand 2 Non-Preferred, PA

prenatal vit without vit a w/fe bisglycinate- fa-omeg 3 mis

NESTABS DHA brand 2 Non-Preferred, PA

prenatal vitamins w/fe asparto glycinate-folic acid tabs

PRENATE STAR brand 2 Non-Preferred, PA

prenatal w/calcium-vit b6-folic acid-ginger

PRENAISSANCE NEXTPRENAISSANCE NEXT-BZINGIBERFOCALGIN-B


75




prenatal w/calcium-vit b6-vit b12-folic acid-ginger tabs

PRENATE AM brand 2 Non-Preferred, PA

prenatal w/fe asparto glycinate-l methylfolate-folic acid

PRENATE ELITE brand 2 Non-Preferred, PA

prenatal w/fe cbnyl-fe asparto glyc-fa-dss-omega 3 caps

ULTIMATECARE ONE NF generic 1 Non-Preferred, PA

prenatal w/fe fumarate-fa-dss-fish oil caps

TRICARE PRENATAL DHA ONE brand 2 Non-Preferred, PA

prenatal w/fe polysacch cmplx-sod feredetate-fa-omega 3

DUET DHABAL-CARE DHAPRENAISSANCE HAVENA-BAL DHAPRENAISSANCE

HARMONY DHAVENA-BAL DHAVIRT-BAL DHA COMBO

PACK


prenatal w/o a vit w/fe fumarate-l methylfolate-folic acid

VITAFOL-NANO brand 2 Non-Preferred, PA

prenatal w/o a w/ fe asparto glyc-l methylfolate-fa-dha

PRENATE PIXIEPRENATE DHA


prenatal w/o vit a w/fe carbonyl-dss-fa-dha caps

ZATEAN-CH CAPSULEMACNATAL CN DHA

SOFTGELINFANATE BALANCE

SOFTGELPRENAISSANCE

BALANCE SOFTGEL


prenatal w/o vit a w/fe carbonyl-fe asp glyc-methfol-fa-dh

PRENATE MINI brand 2 Non-Preferred, PA

76




prenatal w/o vit a w/fe carbonyl-fe aspart glyc-fa-fish oi

OB COMPLETE ONE brand 2 Non-Preferred, PA

prenatal w/o vit a w/fe carbonyl-fe aspart glyc-fa-omega 3

OB COMPLETE PETITE brand 2 Non-Preferred, PA

prenatal w/o vit a w/fe carbonyl-fe gluconate-dss-fa-dha

PRENAISSANCE PROMISE

PRENAISSANCE 90 DHACITRANATAL ASSURE

COMBO PACKCITRANATAL 90 DHA PACK


prenatal w/o vit a w/fe carbonyl-fe gluconate-fa & vit b6

CITRANATAL B-CALM brand 2 Non-Preferred, PA

prenatal w/o vit a w/fe carbonyl-folic acid-dha caps

ACTIVE OB brand 2 Non-Preferred, PA

prenatal w/o vit a w/fe fumarate-dss-fa-dha

PRENEXA, TRIVEEN-PRX RNF

PREFOL-DHAVIRTPREXVEMAVITE-PRX 2PNV-DHA+DOCUSATEFOLCAL DHATARON-PREXFOLIVANE-PRX DHA NFTL-SELECTPRENAISSANCEVIRT-SELECT


prenatal w/o vit a w/fe fumarate-fe carbonyl-dss-fa-dha ca

CITRANATAL HARMONY brand 2 Non-Preferred, PA

prenatal w/o vit a w/fe fumarate-docusate ca-folic acid-dha

EXTRA-VIRT PLUS DHANEXA PLUS SOFTGEL


77




prenatal without a vit w/fe fumarate-folic acid chew

PRENATA brand 2 Non-Preferred, PA

prenatal without a vit w/fe fum-iron polysacch complex -fa

PROVIDA OBCONCEPT OBFOLIVANE-OBVINATE ICPUREFE OB


prenatal without a w/fe asp glyc-l methylfolate-fa- omega 3

PRENATE ESSENTIAL brand 2 Non-Preferred, PA

prenatal without a w/fe carbonyl-l methylfolate-fa-dha

PRENATE MINITRISTART DHAPNV-DHAPRENATE RESTOREPRENATE DHAPRENATE ENHANCE


prenatal without a w/fe fumarate-l methylfolate-fa- omega 3

ZATEAN-PN PLUSPNV-OMEGA SOFTGEL


prenatal without a w/fe fum-fe polysacch complex-fa-dha cap

PROVIDA DHA brand 2 Non-Preferred, PA

prenatal without vit a w/fe fumarate-fa-fish oil misc

TRICARE PRENATAL COMPLEAT brand 2 Non-Preferred, PA

prenatal without vit a w/fe fumarate-l methylfolate-omegas

NEEVO DHAVINATE DHA RF GELCAP


prenatal without vit a w/fe fum-fa-omega fatty acids caps

CALCIUM PNV brand 2 Non-Preferred, PA

prenatal without vit a w/iron carbonyl-folic acid & vit b6

TARON-BC brand 2 Non-Preferred, PA

78




prenatal without vit a w/iron polysaccharide complex-fa ca

MARNATAL-F brand 2 Non-Preferred, PA

pyridoxine HCL inj soln PYRIDOXINE HCL INJ generic 1selenious acid inj soln SELENIUM INJ generic 1sodium ferric gluconate

complex in sucrose soln

FERRLECIT brand 2

sodium iodide soln IODOPEN brand 2thiamine HCL inj soln THIAMINE HCL INJ generic 1

trace min (cr-cu-mn-se-zn) inj

MULTITRACE-5 CONCENTRATE

MULTITRACE-5MULTITRACE-4

CONCENTRATEMULTITRACE-4

NEONATALMULTITRACE-4

PEDIATRICTRACE ELEMENTS 4/

PEDIATRICMULTITRACE-4

generic 1

vitamin A generic 1 OTCvitamin ADC/fluoride/±iron

drops TRI-VI-FLOR generic 1

vitamin B complex/vitamin C/folic acid

DIALYVITEFOLBEE PLUS


vitamin B complex/ vitamin C/folic acid NEPHROCAPS generic 1

vitamin B-1 generic 1 OTCvitamin B-6 generic 1 OTCvitamin C generic 1 OTC

vitamins pediatric TRI-VI-SOL generic 1 members <3 years old, OTC

zinc generic 1 OTCzinc chloride inj soln ZINC TRACE METAL INJ generic 1zinc sulfate inj soln ZINC SULFATE INJ brand 2

79




Potassiumkcl in dextrose & nacl inj POTASSIUM CHLORIDE/

D5W/NACL generic 1

kcl in nacl inj POTASSIUM CHLORIDE/NACL INJ generic 1

phosphorus K-PHOS NEUTRAL generic 1 tabspot bicarbonate &

chloride effer tabEFFERVESCENT POT

CHLORIDE generic 1 Non-Preferred, PA

potassium & sodium acid phosphates tabs K-PHOS NO 2 brand 2 Non-Preferred, PA

potassium acetate inj soln POTASSIUM ACETATE INJ generic 1potassium acid phosphate K-PHOS ORIGINAL brand 2potassium bicarbonate/

potassium citrate effervescent

K-LYTE generic 1 tabs

potassium chloride K-LOR generic 1 powderpotassium chloride POTASSIUM CHLORIDE generic 1 liquidpotassium chloride cpcr MICRO-K 8 brand 2 Non-Preferred, PA

potassium chloride extended-release

K-DUR 10K-DUR 20KLOR-CON 8 KLOR-CON 10

generic 1 tabs

potassium chloride extended-release K-TAB 20 generic 1 Non-Preferred, PA

potassium chloride extended-release MICRO-K 8 generic 1 Non-Preferred, PA

potassium chloride extended-release MICRO-K 10 generic 1 caps

potassium chloride in d5w lactated ringer KCL/D5W/LR IV LAC RING generic 1

potassium chloride in dextrose inj

POTASSIUM CHLORIDE/D5W generic 1

potassium chloride microencapsulated crystals cr tbcr

KLOR-CON M15 brand 2 Non-Preferred, PA

potassium chloride soln POTASSIUM CHLORIDE INJ generic 1

80




potassium citrate (alkalinizer) tbcr UROCIT-K 15 generic 1 Non-Preferred, PA

potassium citrate-citric acid pack CYTRA K CRYSTALS generic 1 Non-Preferred, PA

potassium iodide soln SSKI generic 1 Non-Preferred, PApotassium phosphates inj

solnPOTASSIUM

PHOSPHATES generic 1

Miscellaneous

Anaphylaxis

epinephrineEPIPEN EPIPEN JR.

generic 1 QL

Antidotesacetylcysteine CETYLEV brand 2acetylcysteine (antidote)

soln ACETADOTE INJ generic 1 Non-Preferred, PA

succimer CHEMET brand 2 QLCaloric Agentsalcohol soln DEHYDRATED ALCOHOL generic 1amino acids-dextrose-lipids

with electrolytes emulPERIKABIVENKABIVEN


cysteine HCL soln L-CYSTEINE HCL generic 1dietary management

product - tab cr DERMANIC brand 2 Non-Preferred, PA

Cystic Fibrosisacetylcysteine MUCOMYST generic 1aztreonam CAYSTON brand 2 Diagnosis Required, SPdornase alfa PULMOZYME brand 2 Diagnosis Required, SP

ivacaftorKALYDECOKALYDECO GRANULES

brand 2 PA, SP

lumacaftor/ivacaftor ORKAMBI brand 2 PA, SPsodium chloride for

nebulizerHYPERSALNEBUSAL

generic 1

tobramycin neb soln BETHKIS brand 2 Diagnosis Required, SPtobramycin neb soln TOBI brand 2 Non-Preferred, PA

81




Electrolyte Maintenance

amino acid electrolyte infusion soln inj

PROCALAMINEAMINOSYN MAMINOSYNAMINOSYN II

brand 2

amino acid electrolyte w/calcium infusion in d5w soln

CLINIMIX E/DEXTROSE 5% brand 2









amino acid infusion in d5w soln

CLINIMIX/DEXTROSE 5% brand 2

amino acid infusion in d10w soln CLINIMIX/DEXTROSE 10% brand 2




82




amino acid infusion soln

AMINOSYNAMINOSYN-RFNEPHRAMINETROPHAMINEFREAMINE HBCAMINOSYN IIHEPATAMINEFREAMINE IIICLINISOL SFPROSOL

brand 2

dextrose 5% in lactated ringers

DEXTROSE 5%/ LACTATED RINGERS generic 1

dextrose iv soln DEXTROSE generic 1dextrose w/sodium

chloride DEXTROSE/NACL generic 1

electrolyte-48 in d5w solnDEXTROSE 5%/

ELECTROLYTE #48 VIAFLEX

brand 2

electrolyte-56 in d5w soln PLASMA-LYTE-56/D5W brand 2electrolyte-148 solution PLASMA-LYTE-148 generic 1electrolyte-a solution PLASMA-LYTE A brand 2

electrolyte-b in d5w soln IONOSOL-B/DEXTROSE 5% brand 2

electrolyte-m in d5w soln NORMOSOL-M IN D5W generic 1

electrolyte-mb in d5w soln IONOSOL-MB/ DEXTROSE 5% brand 2

electrolyte-p in d5w soln ISOLYTE-P/DEXTROSE 5% brand 2electrolyte-r solution NORMOSOL-R generic 1electrolyte-r (ph 7.4)

solution NORMOSOL-R generic 1

electrolyte-r in d5w soln NORMOSOL-R IN D5W generic 1electrolyte-s solution ISOLYTE-S brand 2electrolyte-s (ph 7.4)

solution ISOLYTE-S PH 7.4 brand 2

fat emulsion ivLIPOSYN IIIINTRALIPID

generic 1

lactated ringer's solution LACTATED RINGERS generic 1parenteral electrolyte conc NUTRILYTE generic 1

83




parenteral electrolyte soln HYPERLYTE-CR generic 1ringer's solution RINGERS INJECTION generic 1sodium acetate inj soln SODIUM ACETATE INJ generic 1sodium bicarbonate inj

solnSODIUM BICARBONATE

INJ generic 1

sodium chloride soln SODIUM CHLORIDE INJ generic 1sodium chloride

(gu irrigant) solnSODIUM CHLORIDE 0.9%

INJ generic 1

sodium lactate inj soln SODIUM LACTATE INJ generic 1sodium phosphate inj soln SODIUM PHOSPHATE INJ generic 1Hereditary Angioedemaicatibant FIRAZYR brand 2 PA, SPc1 esterase inhibitor

(recombinant) RUCONEST brand 2 Non-Preferred, PA

c1 inhibitor, human CINRYZE brand 2 Non-Preferred, PAc1 esterase inhibitor,

humanBERINERTHAEGARDA

brand 2 PA, SP

Hyperphosphatemiacalcium acetate generic 1 667 mg tablet onlycalcium acetate

(phosphate binder) PHOSLO generic 1 Non-Preferred, PA

cinacalcet SENSIPAR brand 2 PAsevelamer RENVELA generic 1 STIdiopathic Pulmonary Fibrosis (IPF)nintedanib OFEV brand 2 PA, SPpirfenidone capsule ESBRIET brand 2 PA, SPImmune Thrombocytopenic Purpuraeltrombopag PROMACTA brand 2 PA, SPIron Overloaddeferoxamine mesylate solr DESFERAL INJ generic 1

Irrigating Solutionsacetic acid irrigation soln ACETIC ACID 0.25% generic 1citric acid & d-gluconic

acid soln RENACIDIN brand 2 Non-Preferred, PA

lactated ringer's (irrigation) soln

LACTATED RINGERS IRRIGATION generic 1

ringer's irrigation soln RINGERS IRRIGATION generic 1saline injection

bacteriostaticBACTERIOSTATIC

SODIUM CHLORIDE generic 1

84




saline injection w/benzyl alcohol

SODIUM CHLORIDE BACTERIOSTATIC/BENZYL ALCOHOL

generic 1

sorbitol irrigation soln SORBITOL brand 2sorbitol-mannitol irrig soln SORBITOL-MANNITOL brand 2water for inject,

bacteriostatic benzyl alcohol

BACTERIOSTATIC WATER FOR INJECTION/ BENZYL ALCOHOL

generic 1

water for inject, bacteriostatic parabens

BACTERIOSTATIC WATER PARABENS generic 1

water for injection STERILE WATER FOR INJECTION generic 1

water for irrigation, sterile soln

STERILE WATER IRRIGATION generic 1

water for iv injection STERILE WATER FOR INJECTION generic 1

Local Anestheticsbupivacaine HCl soln MARCAINE generic 1bupivacaine in dextrose

soln BUPIVACAINE SPINAL generic 1

bupivacaine inj 0.25% w/epinephrine preservative free (pf)

BUPIVACAINE/ EPINEPHRINE generic 1

chloroprocaine HCl soln NESACAINE-MPF generic 1lidocaine HCl

(local anesth.) soln LIDOCAINE HCL MDV generic 1

lidocaine in dextrose iv soln

LIDOCAINE HCL/ DEXTROSE IV brand 2

lidocaine inj w/epinephrine

LIDOCAINE/ EPINEPHRINE generic 1

mepivacaine HCl inj soln MEPIVACAINE HCL INJ brand 2Medical Devicesinsulin syringes QLlancets QLspacers QLMetabolic Modifierscarglumic acid CARBAGLU brand 2 PA, SPglycerol phenylbutyrate RAVICTI brand 2 PA, SPsodium phenylbutyrate BUPHENYL generic 1 Diagnosis, SP

85




Vaccinediphtheria-tetanus tox

adsorbed (dt) im DIP/TET PED INJ brand 2 QL

hepatitis a vaccine suspHAVRIXVAQTA

brand 2 QL

hepatitis b vaccine (recombinant)

ENGERIX-BRECOMBIVAX HB

brand 2 QL

hepatitis b vaccine recombinant adjuvanted

HEPLISAV-B brand 2 Age Limits Apply

human papillomavirus (hpv) 9-valent recomb vac GARDASIL 9 brand 2 QL

human papillomavirus (hpv) quadrivalent recombinant vac

GARDASIL brand 2 QL

influenza virus vaccine recombinant hemagglutinin (ha)

FLUBLOK brand 2 QL

influenza virus vaccine split

AFLURIAFLUZONE SPLT

brand 2 QL

influenza virus vaccine split high-dose pf FLUZONE HD PF brand 2 QL

influenza virus vaccine split pf AFLURIA PF brand 2 QL

influenza virus vaccine split quadrivalent

FLUARIX QUADFLULAVAL QUADFLUZONE QUAD

brand 2 QL

influenza virus vaccine tiss-cult subunit FLUCELVAX brand 2 QL

influenza virus vaccine types a&b surface antigen FLUVIRIN brand 2 QL

measles, mumps & rubella virus vaccines for inj M-M-R II brand 2 QL

meningococcal (a, c, y, and w-135) MENOMUNE brand 2 QL

86




meningococcal (a, c, y, and w-135) conjugate vaccine

MENACTRA brand 2 QL

meningococcal (a, c, y, and w-135) oligo conj vac for inj

MENVEO brand 2 QL

pneumococcal 13-valent conjugate PREVNAR 13 brand 2 QL

pneumococcal vaccine polyvalent

PNEUMOVAXPNEUMOVAX 23

brand 2 QL

tet tox-diph-acell pertuss ad ADACEL, BOOSTRIX brand 2 QLtetanus-diphtheria toxoids

(td)TENIVACTET/DIP TOX INJ

brand 2 QL

tetanus immune globulin (human) HYPERTET S/D brand 2 QL

typhoid vaccine VIVOTIF BERNA brand 2 capsulesvaricella virus vac live for

subcutaneous VARIVAX brand 2 QL

zoster vaccine live ZOSTAVAX brand 2 QL, Age Limits ApplyOtherbetaine powd CYSTADANE brand 2 Non-Preferred, PAcromolyn sodium

(mastocytosis) conc GASTROCROM brand 2 Non-Preferred, PA

dextrose (diagnostic aid) soln

DEXTROSE THERMOJECT SYSTEM


eliglustat tartrate caps CERDELGA brand 2 Non-Preferred, PAglycopyrrolate soln GLYCOPYRROLATE INJ generic 1imiglucerase solr CEREZYME brand 2 Non-Preferred, PAlevocarnitine (metabolic

modifiers) oral solution CARNITOR generic 1 Non-Preferred, PA

levocarnitine (metabolic modifiers) tabs CARNITOR generic 1 Non-Preferred, PA

miglustat caps ZAVESCA brand 2 Non-Preferred, PA

87



Generic Drug Name Brand Drug Name Examples

OTC MEDICATIONS

The following is a list of OTC products on the PDL. Some OTC products are listed on the druglist. OTC products covered are restricted to generics when available. Brand names are providedas reference only.

Acneadapalene gel DIFFERIN OTC GEL 0.1%benzoyl peroxide crm, gel, lotion CLEARASILAntifungalsclotrimazole

miconazole crm

tolnaftate

MICATINLOTRIMIN AFTINACTIN

vaginal productsMONISTATGYNE-LOTRIMIN

Antiviralsdocosanol ABREVA OTC CREAMAtopic Dermatitis

emollients

BETACARE CREAM AND LOTIONCETAPHIL CREAM AND LOTIONDERMAPHOR OINTMENTE-OINTMENTGLYCERIN TOPICAL

Cough/Cold AllergyAntihistamines

antihistamines

CHLOR-TRIMETONBENADRYLCLARITINALAVERTZYRTEC

Antihistamine/Decongestant Combinationsbrompheniramine/pseudoephedrine DIMETAPPcetirizine/pseudoephedrine OTC ZYRTEC Dchlorpheniramine/pseudoephedrine ACTIFED

88




loratadine/pseudoephedrineALAVERT ALRG TAB/SINUSALAVERT DALLERGY/CONG

Cough/Cold

antitussives Age edit applied. Not covered for members under the age 2.

ROBITUSSINROBITUSSIN DMROBITUSSIN PEROBITUSSIN CFDELSYM

nasal spraysNEO-SYNEPHRINEAFRINDIMETAPP DRO DECONGES

Diabetesalcohol swabs CURITY ALCOHOL PADSglucose oral tablets

insulin (vials only) HUMULINNOVOLIN

Earwax Removal Productscarbamide peroxide DEBROXFamily Planning

condoms-male

TROJANKIMONOLIFESTYLESTRUSTEXDUREXFANTASY

contraceptive foam DELFENcontraceptive gel GYNOL IIFirst AidBurow’s soln, wet dressings DOMEBOROdermatological baths COLLOIDAL OATMEAL BATHShydrocortisone crm, oint CORTAID

topical antibacterialsNEOSPORINBACITRACIN

89




Gastrointestinal

antacids liquids, chew tabsMYLANTA LIQUIDMAALOX LIQUIDTUMS

antidiarrhealsIMODIUM A-DKAOPECTATE

electrolyte rehydrating soln PEDIALYTEfamotidine PEPCID AClaxative enemas FLEET ENEMA

laxativesDULCOLAXFLEET PHOSPHO-SODA

probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

psyllium METAMUCILrectal crm, suppositories PREPARATION Hsimethicone MYLICONstool softeners COLACEsugar+orthophosphoric acid EMETROLInsomniadoxylamine succinate UNISOMLice Productspermethrin NIXpyrethrins/piperonyl butoxide shampoo RID SHAMPOOMotion Sicknessdimenhydrinate DRAMAMINEmeclizine BONINE

90




Ophthalmicsallergic conjunctivitis ALAWAYartificial tears HYPOTEARS

decongestantsVISINEMURINENAPHCON A

Painacetaminophen tabs, liquid, drops,

suppositories, chew tabs TYLENOL

aspirin tabs, EC tabs, chew tabsBAYERECOTRIN

aspirin with buffers tabs

ibuprofen tabs, chew tabs, susp, and drops ADVILMOTRIN IB

Smoking Cessation Products

nicotine

COMMIT LOZENGES (QUANTITY LIMIT)NICODERM CQ (QUANTITY LIMIT)NICOTINE GUM (QUANTITY LIMIT)NICOTROL (QUANTITY LIMIT)

Urologicaloxybutynin patch OXYTROL FOR WOMEN OTC PATCHVitamins/Mineralsb-complex B-COMPLEX VITAMIN TAB

calciumOS-CAL CALTRATETUMS

iron ferrous fumarate, ferrous gluconate, ferrous sulfate, ferrous bis-glycinate chelate and polysaccharide iron caps

FERGONFEOSOL

magnesium oxide MAG-OXvitamin D 400 IU VITAMIN D 400 IU

vitamins pediatric members <3 years oldVI-DAYLINPOLY-VI-SOLTRI-VI-SOL

vitamins prenatal STUART PRENATALWartssalicylic acid 17%/collodion DUOFILMMiscellaneousfluoride dental rinse PHOS-FLUR

91

Index of Covered Drugs

ALL CAPS = Brand-name drug lower case = Generic drug

Index of Covered DrugsA

abacavir . . . . . . . . . . . . . . .43, 44abacavir/dolutegravir/

lamivudine . . . . . . . . . . . . . 44abacavir/lamivudine . . . . . . . . 43abacavir/lamivudine/

zidovudine . . . . . . . . . . . . . 43abaloparatide inj . . . . . . . . . . . 32abemaciclib . . . . . . . . . . . . . . . . 4ABILIFY DISC TAB . . . . . . . . . 57ABILIFY MAINTENA . . . . . . . . 57ABILIFY SOL . . . . . . . . . . . . . . 58ABILIFY TABLETS . . . . . . . . . 57abiraterone . . . . . . . . . . . . . . . . . 5ABREVA OTC CREAM . . .42, 87ABSORICA . . . . . . . . . . . . . . . 21acalabrutinib . . . . . . . . . . . . . . . 4acamprosate . . . . . . . . . . . . . . 54acarbose . . . . . . . . . . . . . . . . . 31ACCOLATE . . . . . . . . . . . . . . . 65ACCUHIST DROPS . . . . . . . . 59ACCUNEB . . . . . . . . . . . . . . . . 65ACCUPRIL . . . . . . . . . . . . . . . . . 9ACCURETIC . . . . . . . . . . . . . . . 9acebutolol . . . . . . . . . . . . . . . . 10ACETADOTE INJ . . . . . . . . . . . 80acetaminophen

. . . . . . . . . 15-17, 45, 63, 90acetaminophen tabs, liquid,

drops, suppositories, chew tabs . . . . . . . . . . . . . . . . . . . 90

acetazolamide . . . . . . . . . . . . . 53acetazolamide

extended-release . . . . . . . 53acetic acid . . . . . . . . . 26, 27, 83ACETIC ACID 0.25% . . . . . . . 83acetic acid irrigation soln . . . . 83acetic acid-oxyquinoline vaginal

gel . . . . . . . . . . . . . . . . . . . . 50acetic acid/aluminum acetate 26acetic acid/hydrocortisone . . 27acetylcysteine . . . . . . . . . . . . . 80acetylcysteine (antidote) soln 80acidophilus . . . . . . . . . . . . . . . 36ACIDOPHILUS XTRA . . . . . . . 36

acidophilus/bifidus . . . . . . . . . 36ACIDOPHILUS/BIFIDUS

WAFER . . . . . . . . . . . . . . . . 36acidophilus/citrus pectin . . . . 36acidophilus/pectin . . . . . . . . . 36acitretin . . . . . . . . . . . . . . . . . . . 24ACLOVATE . . . . . . . . . . . . . . . . 22ACTIFED . . . . . . . . . . . . . .28, 87ACTIGALL . . . . . . . . . . . . . . . . 37ACTIVE FE . . . . . . . . . . . . . . . . 68ACTIVE OB . . . . . . . . . . . . . . . 76ACTIVELLA . . . . . . . . . . . . . . . 50ACTOPLUSMET . . . . . . . . . . . 31ACTOS . . . . . . . . . . . . . . . . . . . 31ACULAR/ACULAR LS . . . . . . 51acyclovir . . . . . . . . . . . . . . . . . . 42acyclovir topical . . . . . . . . . . . . 42ADACEL, BOOSTRIX . . . . . . . 86ADAGEN . . . . . . . . . . . . . . . . . 29ADALAT CC . . . . . . . . . . . . . . . 11adalimumab . . . . . . . . . . . . . . . 45adapalene . . . . . . . . . . . . .21, 87adapalene gel . . . . . . . . . .21, 87ADDERALL . . . . . . . . . . . .54, 55ADDERALL XR . . . . . . . . . . . . 55ADEMPAS . . . . . . . . . . . . . . . . 13ADLYXIN . . . . . . . . . . . . . . . . . 32ADMELOG SOLOSTAR . . . . . 30ADMELOG VIALS . . . . . . . . . . 30ADVAIR DISKUS . . . . . . . . . . . 65ADVAIR HFA . . . . . . . . . . . . . . 65ADVANCED AM/PM. . . . . . . . 70ADVIL . . . . . . . . . . . . . 15, 46, 90afatinib . . . . . . . . . . . . . . . . . . . . 4AFINITOR . . . . . . . . . . . . . . . . . . 4AFINITOR DISPERZ . . . . . . . . . 4AFLURIA . . . . . . . . . . . . . . . . . 85AFLURIA PF . . . . . . . . . . . . . . . 85AFRIN . . . . . . . . . . . . . . . . .28, 88AGGRENOX . . . . . . . . . . . . . . . 8AGRYLIN . . . . . . . . . . . . . . . . . . 8AIRDUO RESPICLICK . . . . . . 65ALAHIST DM . . . . . . . . . . . . . . 62ALAVERT . . . . . . . 27, 28, 87, 88ALAVERT ALRG TAB/

SINUS . . . . . . . . . . . . . .28, 88

ALAVERT D . . . . . . . . . . . . . . . 88ALAVERT-D . . . . . . . . . . . . . . . 28ALAWAY . . . . . . . . . . . . . . .51, 90ALAWAY OTC . . . . . . . . . . . . . 51albendazole . . . . . . . . . . . . . . . 37ALBENZA . . . . . . . . . . . . . . . . 37albiglutide . . . . . . . . . . . . . . . . 32albuterol . . . . . . . . . . . . . . .64, 65albuterol sulfate . . . . . . . . .64, 65albuterol sulfate tabs . . . . . . . 65alclometasone . . . . . . . . . . . . . 22alcohol soln . . . . . . . . . . . . . . . 80alcohol swabs . . . . . . . . . . . . . 88ALDACTAZIDE . . . . . . . . . . . . 12ALDACTONE . . . . . . . . . . . . . . 12ALDARA . . . . . . . . . . . . . . . . . . 25ALDOMET . . . . . . . . . . . . . . . . 14ALDORIL . . . . . . . . . . . . . . . . . 14ALECENSA . . . . . . . . . . . . . . . . 4alectinib . . . . . . . . . . . . . . . . . . . 4alendronate . . . . . . . . . . . . . . . 32ALESSE . . . . . . . . . . . . . . . . . . 48alfuzosin ER . . . . . . . . . . . . . . . 66alginic acid/sodium

bicarbonate . . . . . . . . . . . . 34ALIGN . . . . . . . . . . . . . . . . .37, 89ALINIA . . . . . . . . . . . . . . . . . . . 41ALINIA SUSPENSION . . . . . . 41alirocumab . . . . . . . . . . . . . . . . 13alitretinoin 1% gel . . . . . . . . . . . 6ALKERAN . . . . . . . . . . . . . . . . . 4allergic conjunctivitis . . . . . . . 90ALLERGY/CONG . . . . . . . . . . 88ALLERY/CONG . . . . . . . . . . . 28allopurinol . . . . . . . . . . . . . . . . 46alogliptin . . . . . . . . . . . . . . . . . . 31alogliptin/metformin . . . . . . . . 31alogliptin/pioglitazone . . . . . . 31alosetron HCL . . . . . . . . . . . . . 34ALPHAGAN . . . . . . . . . . . . . . . 53ALPHAGAN P . . . . . . . . . . . . . 53alprazolam . . . . . . . . . . . . . . . . 54alprazolam conc . . . . . . . . . . . 54ALPRAZOLAM INTENSOL . . 54ALREX . . . . . . . . . . . . . . . . . . . 52ALTACE . . . . . . . . . . . . . . . . . . . 9

92


Index of Covered Drugsalteplase solr . . . . . . . . . . . . . . 14altretamine . . . . . . . . . . . . . . . . . 4alumina/magnesia . . . . . . . . . 34alumina/magnesia/

simethicone . . . . . . . . . . . . 34aluminum acetate . . . . . . .25, 26aluminum chloride topical

solution . . . . . . . . . . . . . . . 25ALUNBRIG . . . . . . . . . . . . . . . . . 4ALUVEA . . . . . . . . . . . . . . . . . . 26amantadine . . . . . . . . . . . .19, 42amantadine tablets . . . . . . . . . 19AMARYL . . . . . . . . . . . . . . . . . 31AMBIEN . . . . . . . . . . . . . . . . . . 57ambrisentan . . . . . . . . . . . . . . . 13AMERGE . . . . . . . . . . . . . . . . . 18AMETHYST . . . . . . . . . . . . . . . 48AMICAR . . . . . . . . . . . . . . . . . . . 8amiloride . . . . . . . . . . . . . . . . . 12amiloride/hydrochlorothiazide 12amino acid electrolyte infusion

soln inj . . . . . . . . . . . . . . . . 81amino acid electrolyte w/

calcium infusion in d10w soln . . . . . . . . . . . . . . . . . . . 81

amino acid electrolyte w/calcium infusion in d15w soln . . . . . . . . . . . . . . . . . . . 81




amino acid infusion in d10w soln . . . . . . . . . . . . . . . . . . . 81





amino acid infusion soln . . . . 82amino acids-dextrose-lipids with

electrolytes emul . . . . . . . . 80aminocaproic acid . . . . . . . . . . 8AMINOCAPROIC ACID INJ . . . 8aminocaproic acid soln . . . . . . 8aminosalicyclic acid . . . . . . . . 37AMINOSYN . . . . . . . . . . . .81, 82AMINOSYN II . . . . . . . . . . .81, 82AMINOSYN M . . . . . . . . . . . . . 81AMINOSYN-RF . . . . . . . . . . . . 82amiodarone HCl tabs . . . . . . . 10amiodarone tabs . . . . . . . . . . . 10amitriptyline . . . . . . . . . . . .18, 56amitriptyline/perphenazine . . 56amlodipine . . . . . . . . . . . . . . . . 11amlodipine besylate-benazepril

HCl . . . . . . . . . . . . . . . . . . . 11amlodipine besylate-olmesartan

medoxomil . . . . . . . . . . . . . 11amlodipine besylate-

valsartan . . . . . . . . . . . . . . 11amlodipine-valsartan-

hydrochlorothiazide . . . . . 11ammonium lactate . . . . . . . . . 25AMNESTEEM . . . . . . . . . . . . . 21amoxapine . . . . . . . . . . . . . . . . 56amoxicillin . . . . . . . . . . . . . . . . 39AMOXICILLIN CAPSULES AND

CHEWABLES . . . . . . . . . . 39amoxicillin tabs . . . . . . . . . . . . 39amoxicillin/clavulanate . . . . . . 39AMOXIL SUSP. . . . . . . . . . . . . 39amphetamine/

dextroamphetamine mixed salts . . . . . . . . . . . . . . .54, 55

amphetamine/dextroamphetamine mixed salts extended-release . . . 55

ampicillin . . . . . . . . . . . . . . . . . 39ampicillin & sulbactam sodium

for inj . . . . . . . . . . . . . . . . . . 39AMPICILLIN SODIUM INJ . . . 39

ampicillin sodium solr . . . . . . 39anagrelide . . . . . . . . . . . . . . . . . 8anakinra . . . . . . . . . . . . . . . . . . 45ANALPRAM-HC . . . . . . . . . . . 22ANAPROX . . . . . . . . . . . . .16, 46anastrozole. . . . . . . . . . . . . . . . . 5ANDROGEL, ANDROGEL

PUMP . . . . . . . . . . . . . . . . . 29anidulafungin solr . . . . . . . . . . 40ANIMI-3/VITAMIN D . . . . . . . . 69ANTABUSE . . . . . . . . . . . . . . . 54antacids liquids, chew tabs . . 89ANTARA . . . . . . . . . . . . . . . . . . 12antidiarrheals . . . . . . . . . . . . . . 89antihistamines . . . . . . . . . .27, 87antitussives . . . . . . . . . 3, 59, 88ANTIVERT . . . . . . . . . . . . . . . . 34ANUSOL HC 2.5% . . . . . . . . . 25APHEDRID TAB . . . . . . . . . . . 64apixaban . . . . . . . . . . . . . . . . . . 7apremilast . . . . . . . . . . . . . . . . 45aprepitant . . . . . . . . . . . . . . . . . 34APRESOLINE . . . . . . . . . . . . . 14APRISO . . . . . . . . . . . . . . . . . . 36APTIVUS . . . . . . . . . . . . . . . . . 44ARALEN . . . . . . . . . . . . . . . . . . 44ARANESP . . . . . . . . . . . . . . . . . 8ARAVA . . . . . . . . . . . . . . . . . . . 45ARCAPTA NEOHALER . . . . . 64ARICEPT . . . . . . . . . . . . . . . . . 14ARICEPT ODT . . . . . . . . . . . . . 14ARIMIDEX . . . . . . . . . . . . . . . . . 5aripiprazole . . . . . . . . . . . .57, 58aripiprazole ER injection . . . . 57aripiprazole injection . . . . . . . 57aripiprazole ODT . . . . . . . . . . . 57aripiprazole soln . . . . . . . . . . . 58ARISTADA . . . . . . . . . . . . . . . . 57armodafinil . . . . . . . . . . . . . . . . 15ARMOUR THYROID . . . . . . . . 33ARNUITY ELLIPTA . . . . . . . . . 64AROMASIN . . . . . . . . . . . . . . . . 5ARTANE . . . . . . . . . . . . . . . . . . 19ARTHROTEC . . . . . . . . . . . . . . 46artificial tears . . . . . . . . . . . . . . 90ASCORBIC ACID INJ . . . . . . . 67

93



ascorbic acid soln . . . . . . . . . . 67asfotase alfa . . . . . . . . . . . . . . . 33ASMANEX HFA . . . . . . . . . . . . 64ASMANEX TWISTHALER . . . 64aspirin . . . . . . . .8, 15, 17, 45, 90aspirin tabs, EC tabs, chew

tabs . . . . . . . . . . . . . . . . . . . 90aspirin with buffers tabs . . . . . 90aspirin-dipyridamole cap sr

12hr . . . . . . . . . . . . . . . . . . . 8aspirin/acetaminophen/

caffeine . . . . . . . . . . . . . . . 15ASTELIN. . . . . . . . . . . . . . . . . . 27ASTEPRO . . . . . . . . . . . . . . . . 27ATABEX PRENATAL . . . . . . . . 74ATARAX . . . . . . . . . . . . . . . . . . 27atazanavir . . . . . . . . . . . . . .43, 44atazanavir sulfate-cobicistat 44atenolol . . . . . . . . . . . . . . . . . . . 10atenolol/chlorthalidone . . . . . 10ATIVAN . . . . . . . . . . . . . . . . . . . 54atomoxetine . . . . . . . . . . . . . . . 55atorvastatin . . . . . . . . . . . . . . . 13atovaquone . . . . . . . . . . . . . . . 41ATRIPLA . . . . . . . . . . . . . . . . . . 43atropine . . . . . . . . . . . 34, 37, 52atropine sulfate . . . . . . . . . . . . 37ATROVENT . . . . . . . . . . . .28, 65ATROVENT HFA . . . . . . . . . . . 65ATROVENT NASAL SPRAY . 28AUBAGIO . . . . . . . . . . . . . . . . . 18AUGMENTIN . . . . . . . . . . . . . . 39auranofin . . . . . . . . . . . . . . . . . 45AVITA . . . . . . . . . . . . . . . . . . . . 21AVODART . . . . . . . . . . . . . . . . 66AVONEX/AVONEX PEN,

REBIF . . . . . . . . . . . . . . . . . 18axitinib . . . . . . . . . . . . . . . . . . . . 4AYGESTIN . . . . . . . . . . . . . . . . 50AZACTAM IN ISO-OSMOTIC

DEXTROSE INJ . . . . . . . . 44AZACTAM INJ . . . . . . . . . . . . . 44azathioprine . . . . . . . . . . . . . 6, 45azelaic acid . . . . . . . . . . . . . . . 21azelaic acid (acne) . . . . . . . . . 21azelastine . . . . . . . . . . . . . .27, 51

azelastine HCl soln . . . . . . . . . 27AZELEX . . . . . . . . . . . . . . . . . . 21azithromycin . . . . . . . . . . . . . . 39azithromycin pack . . . . . . . . . . 39azithromycin solr . . . . . . . . . . . 39AZOPT . . . . . . . . . . . . . . . . . . . 52AZOR . . . . . . . . . . . . . . . . . . . . 11aztreonam . . . . . . . . . . . . .44, 80aztreonam in dextrose soln . . 44aztreonam solr. . . . . . . . . . . . . 44AZULFIDINE . . . . . . . . . . .36, 45AZULFIDINE EN-TABS . . .36, 45

Bb-complex . . . . . . . . . . . . .67, 90B-COMPLEX VITAMIN TAB . .67,

90b-complex w/c-biotin-d-zinc &

folic acid . . . . . . . . . . . . . . . 67b-complex w/c-biotin-e-minerals

& folic acid . . . . . . . . . . . . . 67b-complex w/c-biotin-fe & folic

acid . . . . . . . . . . . . . . . . . . . 67b-complex w/c-zn & folic

acid . . . . . . . . . . . . . . . . . . . 67BACID . . . . . . . . . . . . . . . . .37, 89bacitracin . . . . . . . 22, 51, 53, 88bacitracin-polymyxin-neomycin

hc oint . . . . . . . . . . . . . . . . 22bacitracin/polymyxin/

neomycin/hc . . . . . . . . . . . 51baclofen . . . . . . . . . . . . . . . . . . 47BACTERIOSTATIC SODIUM

CHLORIDE . . . . . . . . . . . . 83BACTERIOSTATIC WATER

FOR INJECTION/BENZYL ALCOHOL . . . . . . . . . . . . . 84

BACTERIOSTATIC WATER PARABENS . . . . . . . . . . . . 84

BACTRIM . . . . . . . . . . . . . . . . . 40BACTRIM DS . . . . . . . . . . . . . . 40BACTROBAN . . . . . . . . . . . . . 22BACTROBAN NASAL . . . . . . 22BAL-CARE DHA . . . . . . . . . . . 75balsalazide . . . . . . . . . . . . . . . . 36

BALZIVA . . . . . . . . . . . . . . . . . . 48BANZEL . . . . . . . . . . . . . . . . . . 20BARACLUDE . . . . . . . . . . . . . . 41BASAGLAR . . . . . . . . . . . . . . . 30BAYER . . . . . . . . . . . . . 8, 45, 90becaplermin gel . . . . . . . . . . . 25beclomethasone . . . . . . . . . . . 64bedaquiline . . . . . . . . . . . . . . . 44BELLADONNA ALKALOIDS &

OPIUM . . . . . . . . . . . . . . . . 15belladonna alkaloids & opium

suppos . . . . . . . . . . . . . . . . 15BENADRYL . . . . . . . . . . . .27, 87benazepril . . . . . . . . . . . . . . . 8, 9benazepril/

hydrochlorothiazide . . . . . . 9BENICAR . . . . . . . . . . . . . . . 9, 10BENICAR HCT . . . . . . . . . . . . 10BENTYL . . . . . . . . . . . . . . . . . . 35BENZAC AC . . . . . . . . . . . . . . 21benzalkonium chloride liqd . . 25BENZEFOAMULTRA . . . . . . . 21benznidazole . . . . . . . . . . . . . . 41benzocaine/antipyrine . . . . . . 27benzonatate . . . . . . . . . . . . . . . 59benzonatate caps . . . . . . . . . . 59BENZOTIC . . . . . . . . . . . . . . . . 27benzoyl peroxide . . . . . . . .21, 87benzoyl peroxide crm, gel,

lotion . . . . . . . . . . . . . . . . . . 87benzoyl peroxide foam . . . . . . 21benztropine . . . . . . . . . . . . . . . 19benzyl alcohol (pediculicide)

lotn . . . . . . . . . . . . . . . . . . . 24BERINERT . . . . . . . . . . . . . . . . 83BETA-VAL . . . . . . . . . . . . . . . . 23BETACARE CREAM AND

LOTION . . . . . . . . . . . . . . . 87BETAGAN . . . . . . . . . . . . . . . . 52betaine powd . . . . . . . . . . . . . . 86betamethasone augmented

dip . . . . . . . . . . . . . . . . . . . . 23betamethasone dip

augmented . . . . . . . . . . . . 23betamethasone dipropionate 23

94


Index of Covered Drugsbetamethasone sod phosphate

& acetate inj susp . . . . . . . 28betamethasone val . . . . . . . . . 23BETAPACE . . . . . . . . . . . .10, 11BETAPACE AF . . . . . . . . . . . . . 11BETASERON . . . . . . . . . . . . . . . 6betaxolol . . . . . . . . . . . . . . . . . . 10bethanechol . . . . . . . . . . . . . . . 66BETHKIS . . . . . . . . . . . . . . . . . 80betrixaban . . . . . . . . . . . . . . . . . 7BEVYXXA . . . . . . . . . . . . . . . . . 7bexarotene caps and

topical gel . . . . . . . . . . . . . . 6BEYAZ, SAFYRAL . . . . . . . . . 48BIAXIN . . . . . . . . . . . . . . . . . . . 39BIAXIN XL . . . . . . . . . . . . . . . . 39bicalutamide . . . . . . . . . . . . . . . 5BICILLIN C-R . . . . . . . . . . . . . . 39BICILLIN L-A . . . . . . . . . . . . . . 39BICITRA . . . . . . . . . . . . . . . . . . 67BILTRICIDE . . . . . . . . . . . . . . . 37BIO-D DRO-MULSION . . . . . . 67BIO-D-MULSIO DRO FORTE 67BIOGAIA . . . . . . . . . . . . . . .37, 89bisoprolol . . . . . . . . . . . . . . . . . 10bisoprolol/

hydrochlorothiazide . . . . . 10BLEPH-10 . . . . . . . . . . . . . . . . 53BONINE . . . . . . . . . . . . . . . . . . 89bosentan . . . . . . . . . . . . . . . . . 13BOSULIF . . . . . . . . . . . . . . . . . . 4bosutinib . . . . . . . . . . . . . . . . . . 4BREO ELLIPTA . . . . . . . . . . . . 65BRETHINE . . . . . . . . . . . . . . . . 65brigatinib . . . . . . . . . . . . . . . . . . 4BRILINTA . . . . . . . . . . . . . . . . . . 8brimonidine . . . . . . . . . . . .24, 53brimonidine tartrate-timolol

maleate ophth soln 53brinzolamide susp . . . . . . . . . 52brinzolamide-brimonidine

tartrate ophth susp . . . . . . 52BROMETANE DX . . . . . . . . . . 61BROMFED DM . . . . . . . . . . . . 59

brompheniramine & phenylephrine . . . . . . . . . . 59

brompheniramine & pseudoephedrine liquid 1-7.5 mg/ml . . . . . . . . . . . 59

brompheniramine/pseudoephedrine 59, 61, 87

brompheniramine/pseudoephedrine/dextromethorphan . . . . . . 59

BSS . . . . . . . . . . . . . . . . . . . . . . 54budesonide . . . . . . . . . . . .36, 65budesonide/formoterol . . . . . 65bumetanide . . . . . . . . . . . . . . . 12BUMETANIDE INJ . . . . . . . . . 12bumetanide soln . . . . . . . . . . . 12BUMEX . . . . . . . . . . . . . . . . . . . 12BUPHENYL . . . . . . . . . . . . . . . 84bupivacaine HCl soln . . . . . . . 84bupivacaine in dextrose soln . 84bupivacaine inj 0.25% w/

epinephrine preservative free (pf) . . . . . . . . . . . . . . . . . . . 84

BUPIVACAINE SPINAL . . . . . 84BUPIVACAINE/

EPINEPHRINE . . . . . . . . . 84buprenorphine . . . . . . . . . . . . 57buprenorphine/naloxone . . . . 57bupropion . . . . . . . . . . . . .57, 58bupropion extended-release . 57bupropion HCL (smoking

deterrent) . . . . . . . . . . . . . . 58Burow’s soln, wet dressings . 88BUSPAR . . . . . . . . . . . . . . . . . . 54buspirone . . . . . . . . . . . . . . . . . 54busulfan . . . . . . . . . . . . . . . . . . . 4butalbital-acetaminophen-

caffeine cap . . . . . . . . . . . . 15butalbital/acetaminophen . . . 15butalbital/acetaminophen/

caffeine . . . . . . . . . . . . . . . 15butalbital/apap/caff/cod . . . . 16butalbital/asa/caff/cod . . . . . 16butalbital/aspirin/caffeine . . . 15butorphanol . . . . . . . . . . . . . . . 16BYDUREON . . . . . . . . . . . . . . . 32

BYETTA . . . . . . . . . . . . . . . . . . 32

CC-NATE DHA . . . . . . . . . . . . . . 74c1 esterase inhibitor

(recombinant) . . . . . . . . . . 83c1 esterase inhibitor, human . 83c1 inhibitor, human . . . . . . . . . 83cabergoline . . . . . . . . . . . .19, 33CABOMETYX . . . . . . . . . . . . . . 4cabozantinib . . . . . . . . . . . . . . . 4CAFERGOT . . . . . . . . . . . . . . . 17calamine . . . . . . . . . . . . . . . . . . 25CALAN . . . . . . . . . . . . . . . .11, 18CALAN SR . . . . . . . . . . . . . . . . 11calcipotriene . . . . . . . . . . . . . . 24calcitonin-salmon . . . . . . . . . . 32calcitriol . . . . . . . . . . . . . . .24, 67CALCITRIOL INJ . . . . . . . . . . . 67calcitriol oral soln . . . . . . . . . . 67calcitriol soln . . . . . . . . . . . . . . 67calcium . . . 2, 11, 22, 33, 67, 70,

77, 81, 83, 90calcium acetate . . . . . . . . . . . . 83calcium acetate (phosphate

binder) . . . . . . . . . . . . . . . . 83calcium carbonate chew . . . . 67calcium chloride (dihydrate)

soln . . . . . . . . . . . . . . . . . . . 67CALCIUM CHLORIDE INJ . . . 67CALCIUM GLUCONATE INJ . 67calcium gluconate soln . . . . . 67CALCIUM PNV . . . . . . . . . . . . 77CALQUENCE . . . . . . . . . . . . . . 4CAMPRAL . . . . . . . . . . . . . . . . 54canagliflozin . . . . . . . . . . . . . . . 31canakinumab . . . . . . . . . . . . . 45CANASA. . . . . . . . . . . . . . . . . . 36CAPCOF . . . . . . . . . . . . . . . . . 62capecitabine . . . . . . . . . . . . . . . 4CAPOTEN . . . . . . . . . . . . . . . . . 8CAPOZIDE . . . . . . . . . . . . . . . . . 9CAPRELSA . . . . . . . . . . . . . . . . 5CAPSAGEL . . . . . . . . . . . . . . . 46capsaicin . . . . . . . . . . . . . . . . . 46

95



captopril . . . . . . . . . . . . . . . . . 8, 9captopril/hydrochlorothiazide . 9CAPZASIN-P . . . . . . . . . . . . . . 46CARAC . . . . . . . . . . . . . . . . . . . 25CARAFATE . . . . . . . . . . . . . . . . 35CARAFATE SUSPENSION . . 35CARBAGLU . . . . . . . . . . . . . . . 84carbamazepine . . . . . . . . . . . . 19carbamazepine extended-

release . . . . . . . . . . . . . . . . 19carbamide peroxide . . . . .27, 88CARBATROL . . . . . . . . . . . . . . 19carbidopa & levodopa ODT . . 19carbidopa-levodopa-

entacapone 19carbidopa/levodopa . . . . . . . . 19carbidopa/levodopa extended-

release . . . . . . . . . . . . . . . . 19carbinoxamine maleate . . . . . 59carbinoxamine maleate

extended-release . . . . . . . 59carbonyl iron susp . . . . . . . . . 67CARDEC DM DRO . . . . . . . . . 62CARDEC DM SYP . . . . . . . . . 63CARDEC DRO . . . . . . . . . . . . . 60CARDEC SYP . . . . . . . . . . . . . 60CARDENE . . . . . . . . . . . . . . . . 11CARDIZEM . . . . . . . . . . . . . . . 11CARDIZEM CD . . . . . . . . . . . . 11CARDIZEM SR . . . . . . . . . . . . 11CARDURA . . . . . . . . . . . . . . 9, 66carglumic acid . . . . . . . . . . . . . 84CARNITOR . . . . . . . . . . . . . . . 86carteolol . . . . . . . . . . . . . . . . . . 52carvedilol . . . . . . . . . . . . . . . . . 10casanthranol-docusate

sodium . . . . . . . . . . . . . . . . 33CASODEX . . . . . . . . . . . . . . . . . 5CASTIVA . . . . . . . . . . . . . . . . . 46CATAFLAM . . . . . . . . . . . .15, 46CATAPRES . . . . . . . . . . . . . . . . . 9CATAPRES-TTS . . . . . . . . . . . . 9CATHFLO ACTIVASE . . . . . . . 14CAYSTON . . . . . . . . . . . . . . . . 80CECLOR . . . . . . . . . . . . . . . . . 38cefaclor . . . . . . . . . . . . . . . . . . . 38

cefadroxil . . . . . . . . . . . . . . . . . 38cefazolin in d5w soln . . . . . . . 38CEFAZOLIN SODIUM . . . . . . . 38cefazolin sodium and dextrose

solr . . . . . . . . . . . . . . . . . . . 38cefazolin sodium solr . . . . . . . 38CEFAZOLIN SODIUM/

DEXTROSE . . . . . . . . . . . . 38cefdinir . . . . . . . . . . . . . . . . . . . 38CEFEPIME . . . . . . . . . . . . . . . . 38cefepime HCL solr . . . . . . . . . 38cefixime . . . . . . . . . . . . . . . . . . 38cefixime susr . . . . . . . . . . . . . . 38cefotaxime sodium solr . . . . . 38CEFOTETAN . . . . . . . . . . . . . . 38cefotetan disodium and dextrose

solr . . . . . . . . . . . . . . . . . . . 38cefotetan disodium solr . . . . . 38CEFOTETAN/DEXTROSE . . . 38CEFOXITIN SODIUM . . . . . . . 38cefoxitin sodium and dextrose

solr . . . . . . . . . . . . . . . . . . . 38cefoxitin sodium solr . . . . . . . . 38cefprozil . . . . . . . . . . . . . . . . . . 38ceftazidime solr . . . . . . . . . . . . 38CEFTIN . . . . . . . . . . . . . . . . . . . 38ceftriaxone sodium and dextrose

solr . . . . . . . . . . . . . . . . . . . 38ceftriaxone sodium solr . . . . . 38CEFTRIAXONE/DEXTROSE . 38cefuroxime axetil . . . . . . . . . . . 38cefuroxime sodium solr . . . . . 38CEFZIL . . . . . . . . . . . . . . . . . . . 38CELEBREX . . . . . . . . . . . . . . . 46celecoxib . . . . . . . . . . . . . . . . . 46CELESTONE-SOLUSPAN . . . 28CELEXA . . . . . . . . . . . . . . . . . . 56CELLCEPT . . . . . . . . . . . . . . . . . 6CELLCEPT INTRAVENOUS . . 6CELONTIN . . . . . . . . . . . . . . . . 20CENTRUM . . . . . . . . . . . . .70, 72CENTRUM SPECIALIST

PRENATAL . . . . . . . . . . . . 72cephalexin . . . . . . . . . . . . . . . . 38cephalexin tabs . . . . . . . . . . . . 38

CERDELGA . . . . . . . . . . . . . . . 86CEREFOLIN . . . . . . . . . . . . . . . 70CEREFOLIN NAC . . . . . . . . . . 70CEREZYME . . . . . . . . . . . . . . . 86ceritinib . . . . . . . . . . . . . . . . . . . . 4certolizumab pegol . . . . . . . . . 45CETAPHIL CREAM AND

LOTION . . . . . . . . . . . . . . . 87cetirizine . . . . . . . . . . . 27, 28, 87cetirizine chew tab . . . . . . . . . 27cetirizine hydrochloride/

pseudoephedrine hydrochloride 12 hours extended-release . . . . . . . 28

cetirizine/pseudoephedrine OTC . . . . . . . . . . . . . . . . . . 87

CETYLEV . . . . . . . . . . . . . . . . . 80CHANTIX . . . . . . . . . . . . . . . . . 58CHEMET . . . . . . . . . . . . . . . . . 80CHILD IBUPRO SUS COLD . 64CHLOR-TRIMETON . . . . .27, 87CHLOR-TRIMETON

ALLERGY . . . . . . . . . . . . . 27CHLOR-TRIMETON SYRUP . 27chloral hydrate . . . . . . . . . . . . . 57chlorambucil . . . . . . . . . . . . . . . 4chlordiazepoxide. . . . . . . .34, 54chlordiazepoxide-

amitriptyline 59chlorhexidine gluconate. . . . . 28chloroprocaine HCl soln . . . . 84chloroquine phosphate . . . . . 44chlorothiazide . . . . . . . . . . . . . 12chlorphen tan/carbetapentane

tan . . . . . . . . . . . . . . . . . . . . 60chlorphen tan/pyrilamine tan/PE

tan . . . . . . . . . . . . . . . . . . . . 60chlorpheniramine &

phenylephrine liquid . . . . 60chlorpheniramine extended-

release . . . . . . . . . . . . . . . . 27chlorpheniramine

maleate . . . . . . . . . . . .27, 60chlorpheniramine maleate

phenylephrine HCL . . . . . 60

96


Index of Covered Drugschlorpheniramine tan/

phenylephrine tan. . . . . . . 60chlorpheniramine w/codeine

liquid . . . . . . . . . . . . . . . . . . 60chlorpheniramine/

dextromethorphan 60, 62, 63chlorpheniramine/

phenylephrine . . . . . . .27, 60chlorpheniramine/

phenylephrine/pyrilamine 27chlorpheniramine/

pseudoephedrine 28, 60, 87chlorpromazine . . . . . . . . . . . . 59CHLORPROMAZINE

HCL INJ . . . . . . . . . . . . . . 59chlorpromazine HCL soln . . . 59chlorpropamide. . . . . . . . . . . . 31chlorthalidone . . . . . . . . . .10, 12chlorzoxazone . . . . . . . . . . . . . 46CHOICE-OB + DHA COMBO

PACK . . . . . . . . . . . . . . . . . 72CHOLBAM . . . . . . . . . . . . . . . . 33cholecalciferol . . . . . . . . . .67, 68cholestyramine . . . . . . . . . . . . 12CHOLESTYRAMINE LIGHT

PACKETS . . . . . . . . . . . . . 12CHOLESTYRAMINE

PACKETS . . . . . . . . . . . . . 12cholic acid . . . . . . . . . . . . . . . . 33choriogonadotropin alfa . . . . . 50chorionic gonadotropin . . . . . 50chromic chloride soln . . . . . . . 68CHROMIUM CHLORIDE . . . . 68ciclopirox . . . . . . . . . . . . . . . . . 23CICLOPIROX OLAMINE . . . . 23ciclopirox olamine crea . . . . . 23cilostazol . . . . . . . . . . . . . . . . . . 8CILOXAN . . . . . . . . . . . . . . . . . 53cimetidine . . . . . . . . . . . . . . . . 34CIMZIA . . . . . . . . . . . . . . . . . . . 45cinacalcet . . . . . . . . . . . . . . . . . 83CINRYZE . . . . . . . . . . . . . . . . . 83CIPRO . . . . . . . . . . . . . . . . . . . 39CIPRO I.V.-IN D5W . . . . . . . . . 39CIPRODEX . . . . . . . . . . . . . . . . 27ciprofloxacin . . . . . . . 27, 39, 53

ciprofloxacin in d5w soln . . . . 39CIPROFLOXACIN IV . . . . . . . . 39ciprofloxacin soln . . . . . . . . . . 39ciprofloxacin/

dexamethasone . . . . . . . . 27citalopram . . . . . . . . . . . . . . . . 56CITRANATAL 90 DHA PACK 76CITRANATAL ASSURE COMBO

PACK . . . . . . . . . . . . . . . . . 76CITRANATAL B-CALM . . . . . . 76CITRANATAL HARMONY . . . 76citric acid & d-gluconic

acid soln . . . . . . . . . . . . . . 83CLAFORAN . . . . . . . . . . . . . . . 38CLARAVIS . . . . . . . . . . . . . . . . 21CLARIFOAM EF . . . . . . . . . . . 24clarithromycin . . . . . . . . . . . . . 39clarithromycin ER . . . . . . . . . . 39CLARITIN . . . . . . . . . . . . . .27, 87CLARITIN-D . . . . . . . . . . . . . . . 62CLEAR EYES REDNESS

RELIEF . . . . . . . . . . . . . . . . 51CLEARASIL . . . . . . . . . . . . . . . 87clemastine . . . . . . . . . . . . . . . . 27CLEOCIN . . . . . . . . . . 21, 44, 50CLEOCIN PHOSPHATE INJ . 44CLEOCIN T . . . . . . . . . . . . . . . 21clidinium & chlordiazepoxide 34CLIMARA . . . . . . . . . . . . . .49, 50CLIMARA PRO . . . . . . . . . . . . 50clindamycin . . . . . . . . 21, 44, 50clindamycin phosphate soln . 44clindamycin phosphate vaginal

supp . . . . . . . . . . . . . . . . . . 50CLINIMIX E/DEXTROSE

10% . . . . . . . . . . . . . . . . . . 81CLINIMIX E/DEXTROSE



25% . . . . . . . . . . . . . . . . . . 81CLINIMIX E/DEXTROSE 5% . 81CLINIMIX/DEXTROSE 10% . 81CLINIMIX/DEXTROSE 15% . 81CLINIMIX/DEXTROSE 20% . 81

CLINIMIX/DEXTROSE 25% . 81CLINIMIX/DEXTROSE 5% . . 81CLINISOL SF . . . . . . . . . . . . . . 82CLINORIL . . . . . . . . . . . . . .16, 46clobazam . . . . . . . . . . . . . . . . . 19clobetasol propionate. . . . . . . 23CLOMIPRAMINE HCL . . . . . . 56clomipramine HCL caps . . . . 56clonazepam . . . . . . . . . . . .19, 54clonazepam ODT . . . . . . . . . . 19clonidine. . . . . . . . . . . . . . . . . . . 9clonidine HCl ptwk . . . . . . . . . . 9clopidogrel . . . . . . . . . . . . . . . . . 8clorazepate . . . . . . . . . . . . . . . 54clotrimazole . . . . . 23, 40, 50, 87clotrimazole with

betamethasone . . . . . . . . . 23clozapine . . . . . . . . . . . . . . . . . 58clozapine ODT . . . . . . . . . . . . . 58CLOZARIL . . . . . . . . . . . . . . . . 58cobalamine combination tab 68cobicistat . . . . . . . . . . . . . . . . . 44cobicistat/elvitegravir/

emtricitabine/tenofovir . . . 44cobimetinib . . . . . . . . . . . . . . . . 4CODAR GF . . . . . . . . . . . . . . . 61codeine sulfate . . . . . . . . . . . . 16codeine-chlorcyclizine liquid . 60codeine-pseudoephedrine-

chlorcyclizine liq 61codeine-pyrilamine syrup . . . 61codeine/acetaminophen . . . . 16codeine/chlorpheniramine/

pseudoephedrine . . . . . . . 60codeine/guaifenesin. . . . . . . . 60codeine/guaifenesin/

pseudoephedrine . . . . . . . 60codeine/promethazine. . . . . . 61codeine/promethazine/

phenylephrine . . . . . . . . . . 61CODIMAL DH . . . . . . . . . . . . . 63COGENTIN . . . . . . . . . . . . . . . 19COLACE . . . . . . . . . . . . . .33, 89COLAZAL . . . . . . . . . . . . . . . . 36colchicine . . . . . . . . . . . . . .17, 46

97



colchicine caps . . . . . . . . . . . . 17colchicine w/probenecid . . . . 17COLESTID . . . . . . . . . . . . . . . . 12colestipol HCl . . . . . . . . . . . . . 12COLISTIMETHATE SODIUM

INJ . . . . . . . . . . . . . . . . . . . 40colistimethate sodium solr . . . 40collagenase oint . . . . . . . . . . . 25COLLOIDAL OATMEAL

BATHS . . . . . . . . . . . . . . . . 88COLOCORT. . . . . . . . . . . . . . . 36COLYTE . . . . . . . . . . . . . . . . . . 33COMBIGAN . . . . . . . . . . . . . . . 53COMBIPATCH . . . . . . . . . . . . . 50COMBIVENT RESPIMAT . . . . 65COMBIVIR . . . . . . . . . . . . . . . . 43COMETRIQ . . . . . . . . . . . . . . . . 4COMMIT LOZENGES . . . . . . . 90COMMITT OTC . . . . . . . . . . . . 58COMPAZINE . . . . . . . . . . . . . . 34COMPLERA . . . . . . . . . . . . . . 43COMPLETE NATALCARE PAK

DHA . . . . . . . . . . . . . . . . . . 71COMTAN . . . . . . . . . . . . . . . . . 19CONCEPT DHA . . . . . . . . . . . 73CONCEPT OB . . . . . . . . . . . . . 77CONCERTA . . . . . . . . . . . . . . . 55condoms-male . . . . . . . . . . . . 88CONDYLOX SOL . . . . . . . . . . 25conjugated estrogen/

bazedoxifene . . . . . . . . . . . 51contraceptive foam . . . . . . . . . 88contraceptive gel . . . . . . . . . . . 88COPAXONE . . . . . . . . . . . . . . . 18COPPER TRACE METAL . . . 68CORDARONE . . . . . . . . . . . . . 10COREG . . . . . . . . . . . . . . . . . . 10CORICIDIN TAB CGH/CLD . . 60CORTAID . . . . . . . . . . . . . . . . . 88CORTEF . . . . . . . . . . . . . . . . . . 29corticotropin gel . . . . . . . . . . . 19cortisone acetate . . . . . . . . . . 29CORTISPORIN . . . . . 22, 27, 51CORTISPORIN OTIC . . . . . . . 27CORTIZONE . . . . . . . . . . . . . . 22

CORTIZONE-10 INTENSIVE HEALING . . . . . . . . . . . . . . 22

CORVITE . . . . . . . . . . . . . . . . . 70CORVITE 150 . . . . . . . . . . . . . 70COSENTYX . . . . . . . . . . . . . . . 45COSOPT . . . . . . . . . . . . . . . . . 52COTELLIC . . . . . . . . . . . . . . . . . 4COUMADIN . . . . . . . . . . . . . . . . 7COZAAR . . . . . . . . . . . . . . . . . . 9CPM/PSE . . . . . . . . . . . . . . . . . 60CREON . . . . . . . . . . . . . . . . . . . 36CREON 3000 UNIT . . . . . . . . 36crisaborole . . . . . . . . . . . . . . . . 25CRIXIVAN . . . . . . . . . . . . . . . . . 43crizotinib . . . . . . . . . . . . . . . . . . . 4crofelemer . . . . . . . . . . . . . . . . 34CROLOM . . . . . . . . . . . . . . . . . 51cromolyn . . . . . . . 28, 51, 65, 86cromolyn sodium . . . 28, 51, 86cromolyn sodium (mastocytosis)

conc . . . . . . . . . . . . . . . . . . 86crotamiton . . . . . . . . . . . . . . . . 24CULTURELLE . . . . . . . . . .37, 89cupric chloride soln . . . . . . . . 68CURITY ALCOHOL PADS . . . 88CUTIVATE . . . . . . . . . . . . . . . . 23cyanocobalamin . . . . . . . . . . . 68CYCLESSA . . . . . . . . . . . . . . . 49cyclobenzaprine . . . . . . . . . . . 46CYCLOGYL . . . . . . . . . . . . . . . 52cyclopentolate . . . . . . . . . . . . . 52cyclophosphamide . . . . . . . . . . 4cycloserine . . . . . . . . . . . . . . . . 37cyclosporine . . . . . . . . . . . . 6, 53cyclosporine (ophth) emul . . . 53cyclosporine inj . . . . . . . . . . . . . 6cyclosporine oral solution . . . . 6cyclosporine, modified . . . . . . . 6CYKLOKAPRON . . . . . . . . . . . 51CYMBALTA . . . . . . . . . . . . . . . 56cyproheptadine . . . . . . . . . . . . 27CYSTADANE . . . . . . . . . . . . . . 86CYSTAGON . . . . . . . . . . . . . . . . 7CYSTARAN . . . . . . . . . . . . . . . 54cysteamine 0.44% ophthalmic

solution . . . . . . . . . . . . . . . 54

cysteamine bitartrate . . . . . . . . 7cysteine HCL soln . . . . . . . . . . 80CYTOMEL . . . . . . . . . . . . . . . . 33CYTOTEC . . . . . . . . . . . . . . . . 37CYTOVENE . . . . . . . . . . . . . . . 41CYTOXAN . . . . . . . . . . . . . . . . . 4CYTRA K CRYSTALS . . . . . . . 80CYTRA-3 . . . . . . . . . . . . . . . . . 71

DD3-50 CAP . . . . . . . . . . . . . . . . 67D.H.E. 45 . . . . . . . . . . . . . . . . . 17dabigatran etexilate mesylate

caps . . . . . . . . . . . . . . . . . . . 7dabrafenib . . . . . . . . . . . . . . . . . 4daclizumab . . . . . . . . . . . . . . . 18DALIRESP . . . . . . . . . . . . . . . . 66DALLERGY, NASOHIST . . . . . 60DALMANE . . . . . . . . . . . . . . . . 57dalteparin sodium soln . . . . . . . 7danazol . . . . . . . . . . . . . . . . . . . 49DANOCRINE . . . . . . . . . . . . . . 49DANTRIUM . . . . . . . . . . . . . . . 47dantrolene . . . . . . . . . . . . . . . . 47dapsone . . . . . . . . . . . . . . . . . . 44DARAPRIM . . . . . . . . . . . . . . . 45darbepoetin alfa . . . . . . . . . . . . 8darunavir . . . . . . . . . . . . . .43, 44darunavir/cobicistat . . . . . . . . 44dasatinib . . . . . . . . . . . . . . . . . . . 4DAYPRO . . . . . . . . . . . . . . .16, 46DAYTRANA . . . . . . . . . . . . . . . 55DAZIDOX . . . . . . . . . . . . . . . . . 17DDAVP . . . . . . . . . . . . . . . . . . . 33DEBROX . . . . . . . . . . . . . .27, 88DECADRON . . . . . . . . . . . . . . 29decongestants . . . 3, 28, 59, 90deferasirox . . . . . . . . . . . . . . . . . 8deferoxamine mesylate solr . . 83DEHYDRATED ALCOHOL . . 80DELATESTRYL . . . . . . . . . . . . 29delavirdine . . . . . . . . . . . . . . . . 42DELESTROGEN INJ . . . . . . . . 49DELFEN . . . . . . . . . . . . . . . . . . 88DELSYM . . . . . . . . . . . . . . .61, 88DELTASONE . . . . . . . . . . . . . . 29

98


Index of Covered DrugsDELZICOL . . . . . . . . . . . . . . . . 36DEMADEX . . . . . . . . . . . . . . . . 12DEMEROL . . . . . . . . . . . . . . . . 17DENAVIR . . . . . . . . . . . . . . . . . 25DEPAKENE . . . . . . . . . . . . . . . 20DEPAKOTE . . . . . . . . 18, 19, 55DEPAKOTE ER . . . . . . . . . . . . 19DEPAKOTE

SPRINKLE . . . . . . 18, 19, 55DEPEN TITRATAB . . . . . . . . . 45DEPO-MEDROL . . . . . . . . . . . 29DEPO-PROVERA . . . . . . . . . . 47DEPO-SUBQ PROVERA 104 47DEPO-TESTOSTERONE . . . . 29DERMA-SMOOTHE OIL/FS . 22DERMANIC . . . . . . . . . . . . . . . 80DERMAPHOR OINTMENT . . 87dermatological baths . . . . . . . 88DERMATOP . . . . . . . . . . . . . . . 23DERMOTIC OIL . . . . . . . . . . . . 27DESCOVY . . . . . . . . . . . . . . . . 43DESENEX . . . . . . . . . . . . . . . . 24DESFERAL INJ . . . . . . . . . . . . 83desipramine . . . . . . . . . . . . . . . 56desmopressin . . . . . . . . . . . . . 33desmopressin acetate soln . . 33desogestrel/EE . . . . . . . . . 47-49desvenlafaxine succinate

tb24 . . . . . . . . . . . . . . . . . . 55DESYREL . . . . . . . . . . . . . . . . . 57DETROL . . . . . . . . . . . . . . . . . . 67dexamethasone . 27, 29, 51, 52dexamethasone (ophth) susp 52DEXAMETHASONE SODIUM

PHOSPHATE . . . . . . . .29, 52dexamethasone sodium

phosphate soln . . . . . . . . . 29DEXASOL . . . . . . . . . . . . . . . . 52DEXEDRINE . . . . . . . . . . . . . . 55dexmethylphenidate HCL

cp24 . . . . . . . . . . . . . . . . . . 55dexmethylphenidate HCL

tabs . . . . . . . . . . . . . . . . . . . 55dextroamphetamine . . . . .54, 55dextromethorphan hbr . . . . . . 61

dextromethorphan polistirex extended-release . . . . . . . 61

dextromethorphan- guaifenesin 61

dextromethorphan-guaifenesin syrup . . . . . . . . . . . . . . . . . 61

dextromethorphan/brompheniramine/pseudoephedrine . . . . . . . 61

dextromethorphan/ guaifenesin . . . . . 61, 63, 64

dextromethorphan/promethazine . . . . . . . . . . 61

dextromethorphan/quinidine 59DEXTROSE . 14, 38, 41, 44, 79,

81, 82, 84, 86dextrose (diagnostic aid) soln 86dextrose 5% in lactated

ringers . . . . . . . . . . . . . . . . 82DEXTROSE 5%/ELECTROLYTE

#48 VIAFLEX . . . . . . . . . . 82DEXTROSE 5%/LACTATED

RINGERS . . . . . . . . . . . . . . 82dextrose iv soln . . . . . 14, 82, 84DEXTROSE THERMOJECT

SYSTEM . . . . . . . . . . . . . . . 86dextrose w/sodium chloride . 82DEXTROSE/NACL . . . . . .79, 82DIABINESE . . . . . . . . . . . . . . . 31DIALYVITE . . . . . . . . . 67, 70, 78DIALYVITE 3000 . . . . . . . . . . . 67DIALYVITE 5000 . . . . . . . . . . . 67DIALYVITE 800/IRON . . . . . . 67DIALYVITE SUPREME D . . . . 70DIAMOX SEQUELS . . . . . . . . 53DIASTAT ACUDIAL . . . . . . . . . 19diazepam . . . . . . . . . . 19, 47, 54diazepam conc . . . . . . . . . . . . 54DIAZEPAM INTENSOL . . . . . 54diazoxide susp . . . . . . . . . . . . 29diclofenac 1% gel . . . . . . . . . . 46diclofenac potassium . . . .15, 46diclofenac sodium . . 15, 46, 51diclofenac sodium delayed-

release . . . . . . . . . . . . .15, 46

diclofenac sodium extended-release . . . . . . . . . . . . . . . . 46

diclofenac w/misoprostol . . . 46dicloxacillin . . . . . . . . . . . . . . . 39dicyclomine . . . . . . . . . . . . . . . 35didanosine . . . . . . . . . . . . . . . . 43didanosine delayed-release . . 43DIDRONEL. . . . . . . . . . . . . . . . 32dietary management product -

tab cr . . . . . . . . . . . . . . . . . 80DIFFERIN . . . . . . . . . . . . . .21, 87DIFFERIN OTC GEL 0.1% 21, 87DIFICID . . . . . . . . . . . . . . . . . . . 39DIFLUCAN . . . . . . . . . . . . .40, 50DIGESTIVE PROBIOTIC .37, 89digoxin . . . . . . . . . . . . . . . . . . . 10DIHISTINE DH . . . . . . . . . . . . . 60DIHYDRO-PE SYP . . . . . . . . . 63dihydroergotamine . . . . . . . . . 17DILACOR XR . . . . . . . . . . . . . . 11DILANTIN . . . . . . . . . . . . . . . . . 20DILANTIN INFATABS . . . . . . . 20DILAUDID . . . . . . . . . . . . . . . . 17diltiazem . . . . . . . . . . . . . . . . . . 11diltiazem extended-release . . 11diltiazem HCl coated beads

tb24 . . . . . . . . . . . . . . . . . . 11diltiazem sustained-release . . 11DIMEATAPP DRO

DECONGES . . . . . . . . . . . 28dimenhydrinate . . . . . . . . . . . . 89DIMETAPP . . 59, 60, 63, 87, 88DIMETAPP CLD ELX/

ALLERGY . . . . . . . . . . . . . 59DIMETAPP DRO DCON/CGH 63DIMETAPP DRO DECONGES 88DIMETAPP SYP CGH/CLD . . 60dimethyl fumarate . . . . . . . . . . 18DIOVAN . . . . . . . . . . . . . . . . . . . 9DIOVAN HCT . . . . . . . . . . . . . . . 9DIP/TET PED INJ . . . . . . . . . . 85DIPENTUM . . . . . . . . . . . . . . . 36diphenhydramine . . . . . . .27, 57DIPHENHYDRAMINE

HCL INJ . . . . . . . . . . . . . . . 27diphenhydramine HCl soln . . 27

99



diphenoxylate/atropine . . . . . 34diphtheria-tetanus tox adsorbed

(dt) im . . . . . . . . . . . . . . . . . 85DIPROLENE . . . . . . . . . . . . . . 23DIPROLENE AF . . . . . . . . . . . 23dipyridamole . . . . . . . . . . . . . . . 8DISALCID . . . . . . . . . . . . . . . . . 46disopyramide . . . . . . . . . . . . . . 10disopyramide

extended-release . . . . . . . 10disulfiram . . . . . . . . . . . . . . . . . 54DITROPAN . . . . . . . . . . . . . . . . 66DITROPAN XL . . . . . . . . . . . . . 66DIURIL . . . . . . . . . . . . . . . . . . . 12DIURIL ORAL

SUSPENSION . . . . . . . . . . 12divalproex sodium cap

sprinkle . . . . . . . . 18, 19, 55divalproex sodium delayed-

release . . . . . . . . . 18, 19, 55divalproex sodium tb24 . . . . . 19DOBUTAMINE HCL . . . . . . . . 14dobutamine HCl soln . . . . . . . 14DOBUTAMINE HCL/D5W . . . 14dobutamine in d5w soln . . . . 14DOCETAXEL . . . . . . . . . . . . . . . 7docetaxel soln . . . . . . . . . . . . . . 7docosanol . . . . . . . . . . . . .42, 87docusate calcium plus . . . . . . 33docusate potasssium . . . . . . . 33docusate sodium . . . . . . . . . . 33dofetilide. . . . . . . . . . . . . . . . . . 10dolutegravir . . . . . . . . . . . .42, 44dolutegravir/rilpivirine . . . . . . . 44DOMEBORO . . . . . . . . . . .26, 88DOMEBORO OTIC . . . . . . . . . 26donepezil . . . . . . . . . . . . . . . . . 14donepezil ODT . . . . . . . . . . . . 14dornase alfa . . . . . . . . . . . . . . . 80dorzolamide . . . . . . . . . . . . . . . 52dorzolamide/timolol maleate 52DOSTINEX . . . . . . . . . . . . . . . . 33DOVONEX . . . . . . . . . . . . . . . . 24doxazosin . . . . . . . . . . . . . . . 9, 66doxepin . . . . . . . . . . . . . . .25, 56

doxepin HCl (antipruritic) cream . . . . . . . . . . . . . . . . . 25

doxercalciferol caps . . . . . . . . 68doxycycline hyclate . . . . . . . . . 40doxycycline monohydrate . . . 40doxylamine succinate . . . .57, 89DRAMAMINE . . . . . . . . . . . . . 89DRISDOL . . . . . . . . . . . . . . . . . 68dronabinol . . . . . . . . . . . . . . . . 34DROPERIDOL . . . . . . . . . . . . . 34droperidol soln . . . . . . . . . . . . 34drospirenon-ethinyl estradiol

tab . . . . . . . . . . . . . . . . . . . . 48drospirenone-ethinyl estrad-

levomefolate tab . . . . . . . . 48DROXIA . . . . . . . . . . . . . . . . . . . 7DUAVEE . . . . . . . . . . . . . . . . . . 51DUET DHA . . . . . . . . . . . . . . . . 75dulaglutide . . . . . . . . . . . . . . . . 32DULCOLAX . . . . . . . . . . . . . . . 89DULERA . . . . . . . . . . . . . . . . . . 65duloxetine . . . . . . . . . . . . . . . . 56duloxetine HCL cpep . . . . . . . 56DUOFILM . . . . . . . . . . . . . .25, 90DUONEB . . . . . . . . . . . . . . . . . 65DURAGESIC . . . . . . . . . . . . . . 16DURATUSS DM ELX . . . . . . . 61DUREX . . . . . . . . . . . . . . . . . . . 88DURICEF . . . . . . . . . . . . . . . . . 38dutasteride caps . . . . . . . . . . . 66DYAZIDE . . . . . . . . . . . . . . . . . 12dyphylline tabs . . . . . . . . . . . . 65

EE-OINTMENT . . . . . . . . . . . . . 87E.E.S. . . . . . . . . . . . . . . . . . . . . 39ecothiophate . . . . . . . . . . . . . . 52ECOTRIN . . . . . . . . . . . 8, 45, 90ED A-HIST TABLETS AND

LIQUID . . . . . . . . . . . . . . . . 60EDGE OB CHW . . . . . . . . . . . 74edoxaban . . . . . . . . . . . . . . . . . . 7EDURANT . . . . . . . . . . . . . . . . 42efavirenz . . . . . . . . . . . . . . .42, 43

efavirenz/emtricitabine/ tenofovir . . . . . . . . . . . . . . . 43

EFFERVESCENT POT CHLORIDE . . . . . . . . . . . . 79

EFFEXOR . . . . . . . . . . . . . . . . . 56EFFEXOR XR . . . . . . . . . . . . . . 56EFFIENT . . . . . . . . . . . . . . . . . . . 8EFUDEX . . . . . . . . . . . . . . . . . . 25EGRIFTA . . . . . . . . . . . . . . . . . 32ELAVIL . . . . . . . . . . . . . . . .18, 56ELDEPRYL . . . . . . . . . . . . . . . . 19electrolyte . . . . . 3, 68, 81-83, 89electrolyte rehydrating soln . . 89electrolyte-148 solution . . . . . 82electrolyte-48 in d5w soln . . . 82electrolyte-56 in d5w soln . . . 82electrolyte-a solution . . . . . . . . 82electrolyte-b in d5w soln . . . . 82electrolyte-m in d5w soln . . . . 82electrolyte-mb in d5w soln. . . 82electrolyte-p in d5w soln . . . . 82electrolyte-r (ph 7.4) solution . 82electrolyte-r in d5w soln . . . . . 82electrolyte-r solution . . . . . . . . 82electrolyte-s (ph 7.4) solution 82electrolyte-s solution . . . . . . . . 82ELELYSO . . . . . . . . . . . . . . . . . 33ELIDEL . . . . . . . . . . . . . . . . . . . 26eliglustat tartrate caps . . . . . . 86ELIMITE . . . . . . . . . . . . . . . . . . 24ELIQUIS . . . . . . . . . . . . . . . . . . . 7ELLA . . . . . . . . . . . . . . . . . . . . . 47ELMIRON . . . . . . . . . . . . . . . . . 66ELOCON . . . . . . . . . . . . . . . . . 23eltrombopag . . . . . . . . . . . . . . 83elvitegravir . . . . . . . . . . . . .42, 44elvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate . . . 44

EMCYT . . . . . . . . . . . . . . . . . . . . 4EMEND . . . . . . . . . . . . . . . . . . 34EMETROL . . . . . . . . . . . . . . . . 89emicizumab-kxwh . . . . . . . . . . . 8EMLA . . . . . . . . . . . . . . . . . . . . 26emollients . . . . . . . . . . . . . . . . . 87emtricitabine . . . . . . . . . . .43, 44

100


Index of Covered Drugsemtricitabine/rilpivirine/

tenofovir . . . . . . . . . . . . . . . 43emtricitabine/tenofovir

alafenamide . . . . . . . . .43, 44emtricitabine/tenofovir

disoproxil . . . . . . . . . . . . . . 43EMTRIVA . . . . . . . . . . . . . . . . . 43enalapril . . . . . . . . . . . . . . . . . 8, 9enalapril oral soln . . . . . . . . . . . 8enalapril/hydrochlorothiazide . 9ENBRACE HR . . . . . . . . . . . . . 73ENBREL . . . . . . . . . . . . . . . . . . 45ENFAMIL EXPECTA . . . . . . . . 72enfuvirtide . . . . . . . . . . . . . . . . 44ENGERIX-B . . . . . . . . . . . . . . . 85enoxaparin . . . . . . . . . . . . . . . . . 7entacapone . . . . . . . . . . . . . . . 19entecavir . . . . . . . . . . . . . . . . . . 41ENTERIC COATED-

NAPROSYN . . . . . . . . .16, 46ENTOCORT EC . . . . . . . . . . . . 36ENTRESTO . . . . . . . . . . . . . . . 10ENULOSE . . . . . . . . . . . . . . . . 33EPANED . . . . . . . . . . . . . . . . . . . 8EPCLUSA . . . . . . . . . . . . . . . . . 42epinephrine . . . . . . . . . . . .80, 84EPIPEN . . . . . . . . . . . . . . . . . . . 80EPIPEN JR. . . . . . . . . . . . . . . . 80EPIVIR . . . . . . . . . . . . . . . .41, 43EPIVIR HBV . . . . . . . . . . . . . . . 41epoetin alfa . . . . . . . . . . . . . . . . 8EPOGEN . . . . . . . . . . . . . . . . . . 8epoprostenol sodium solr . . . 14EPZICOM . . . . . . . . . . . . . . . . . 43ERAXIS . . . . . . . . . . . . . . . . . . . 40ergocalciferol (D2) . . . . . . . . . 68ergotamine tartrate/ caffeine . 17ergotamine/caffeine . . . . . . . . 17ERIVEDGE . . . . . . . . . . . . . . . . . 7erlotinib . . . . . . . . . . . . . . . . . . . 4ertapenem sodium solr . . . . . 40ertugliflozin . . . . . . . . . . . . . . . 31ertugliflozin/metformin . . . . . . 31ERY-TAB . . . . . . . . . . . . . . . . . . 39ERYC . . . . . . . . . . . . . . . . . . . . 39ERYGEL . . . . . . . . . . . . . . . . . . 21

ERYTHROCIN . . . . . . . . . . . . . 39erythromycin . . . . . . . 21, 39, 53erythromycin delayed-release 39erythromycin ethylsuccinate . 39erythromycin stearate . . . . . . . 39erythromycin/sulfisoxazole . . 39ESBRIET . . . . . . . . . . . . . . . . . 83ESCAVITE . . . . . . . . . . . . . . . . 71ESCAVITE D . . . . . . . . . . . . . . 71ESCAVITE LQ . . . . . . . . . . . . . 71escitalopram . . . . . . . . . . . . . . 56ESGIC . . . . . . . . . . . . . . . . . . . . 15ESKALITH CR . . . . . . . . . . . . . 56esomeprazole . . . . . . . . . .34, 35esomeprazole granules . . . . . 35esterified estrogens . . . . . . . . 49ESTRACE . . . . . . . . . . . . . . . . . 49estradiol . . . . . . . . . . . . . . . 47-50estradiol & norethindrone

acetate . . . . . . . . . . . . . . . . 50estradiol patch twice weekly . 49estradiol vaginal ring . . . . . . . 49estradiol valerate oil . . . . . . . . 49estradiol valerate-dienogest 47estradiol-levonorgestrel td patch

weekly . . . . . . . . . . . . . . . . 50estradiol-norethindrone ace td

patch twice weekly . . . . . . 50estramustine phosphate

sodium . . . . . . . . . . . . . . . . . 4ESTRING . . . . . . . . . . . . . . . . . 49estrogens, conjugated . . .49, 50estrogens, conjugated/

medroxyprogesterone . . . 50estropipate . . . . . . . . . . . . . . . . 49ESTROSTEP FE . . . . . . . . . . . 49etanercept . . . . . . . . . . . . . . . . 45ethambutol . . . . . . . . . . . . . . . . 37ethionamide . . . . . . . . . . . . . . . 38ethosuximide . . . . . . . . . . . . . . 19ethotoin tabs . . . . . . . . . . . . . . 19ethynodiol diacetate/EE . .48, 49etidronate . . . . . . . . . . . . . . . . . 32etodolac . . . . . . . . . . . . . . .15, 46etonogestrel/EE . . . . . . . . . . . 47etoposide . . . . . . . . . . . . . . . . . . 7

etravirine . . . . . . . . . . . . . . . . . . 42EUCRISA . . . . . . . . . . . . . . . . . 25EULEXIN . . . . . . . . . . . . . . . . . . 5EURAX . . . . . . . . . . . . . . . . . . . 24everolimus . . . . . . . . . . . . . . . 4, 6EVISTA . . . . . . . . . . . . . . . . . . . 32EVOTAZ . . . . . . . . . . . . . . . . . . 44EXCEDRIN MIGRAINE . . . . . . 15EXELON . . . . . . . . . . . . . . . . . . 15exemestane . . . . . . . . . . . . . . . . 5exenatide . . . . . . . . . . . . . . . . . 32exenatide pen . . . . . . . . . . . . . 32exenatide sopn . . . . . . . . . . . . 32EXFORGE . . . . . . . . . . . . . . . . 11EXFORGE HCT . . . . . . . . . . . . 11EXJADE . . . . . . . . . . . . . . . . . . . 8exogabine . . . . . . . . . . . . . . . . 19EXTINA . . . . . . . . . . . . . . . . . . . 24EXTRA-VIRT PLUS DHA . . . . 76ezetimibe tabs . . . . . . . . . . . . . 13

FFALESSA . . . . . . . . . . . . . . . . . 48famotidine . . . . . . . . . . . . .35, 89famotidine in nacl soln . . . . . . 35FAMOTIDINE INJ . . . . . . . . . . 35famotidine oral suspension . . 35FAMOTIDINE PREMIXED IV . 35famotidine soln . . . . . . . . . . . . 35FANAPT . . . . . . . . . . . . . . . . . . 58FANAPT TITRATION PACK . . 58FANTASY . . . . . . . . . . . . . . . . . 88FARESTON . . . . . . . . . . . . . . . . 5FARYDAK . . . . . . . . . . . . . . . . . . 4fat emulsion iv . . . . . . . . . . . . . 82FAZACLO . . . . . . . . . . . . . . . . . 58fe asp gly-fe polys-succ acd-b

cmplx-c-ca-fa tab ther pk . 68fe asparto gly-b12-fa-c-dss-

succinic acid-zn tab 75-1 mg . . . . . . . . . . . . . . . 68

fe bisglycinate-fe polysacch-vit c-vit b12-fa cap . . . . . . . . . 68

fe carbonyl-fa-b complex-a-c-d-e-min tab 75-1.25 mg . . . . . 68

101



fe carbonyl-fe gluconate-fa-vit b12-vit c-dss tab 90-1 mg . . . . . . . . . . . . . . . 68

fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg (125 mg fe) . . . . . . . . . . . . 68

fe fum-iron poly cmplx-fa-b cmplx-c-biotin-probiotic cap . . . . . . . . . . . . . . . . . . . 68

fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap . . . . . . . . . . . . . . . . . . . 68

fe fum-iron polysacch complex-fa-b complex-c-biotin cap . . . . . . . . . . . . . . . . . . . 68

fe fumarate-vit c-vit b12-fa cap . . . . . . . . . . . . . . . . . . . 69

FE PLUS PROTEIN . . . . . . . . . 69febuxostat . . . . . . . . . . . . . . . . 46felbamate . . . . . . . . . . . . . .19, 20felbamate oral susp . . . . . . . . 20FELBATOL . . . . . . . . . . . . .19, 20FELBATOL ORAL SUSP . . . . 20FELDENE . . . . . . . . . . . . . .16, 46felodipine extended-release . 11FEM PH . . . . . . . . . . . . . . . . . . 50FEMARA . . . . . . . . . . . . . . . . . . 5FEMCON FE . . . . . . . . . . . . . . 48FEMHRT LOW DOSE . . . . . . . 47fenofibrate . . . . . . . . . . . . . . . . 12fenofibrate micronized caps . 12fentanyl transdermal . . . . . . . . 16FEOSOL . . . . . . . . . . . . . . .69, 90FERGON . . . . . . . . . . . . . .69, 90FERIVA 21/7 . . . . . . . . . . . . . . 68FERRALET 90 . . . . . . . . . . . . . 68FERRAPLUS 90 . . . . . . . . . . . 69FERRIMIN 150 . . . . . . . . . . . . 69FERRLECIT . . . . . . . . . . . . . . . 78FERROGELS FORTE . . . . . . . 69ferrous bis-glycinate chelate . 90ferrous fumarate . . . . 47, 69, 90ferrous fumarate tabs . . . . . . . 69ferrous fumarate w/fa-dss-b

complex-vit c tab . . . . . . . . 69

ferrous fumarate-fa-b complex-c-zn-mg-mn-cu cap . . . . . . . 69

ferrous fumarate-folic acid tab 69ferrous gluconate . . . . . . .69, 90ferrous gluconate tabs . . . . . . 69ferrous sulfate . . . . . . . . . .69, 90ferrous sulfate dried tabs . . . . 69ferrous sulfate dried tbcr . . . . 69ferrous sulfate extended-release

tablets . . . . . . . . . . . . . . . . . 69ferrous sulfate liquid . . . . . . . . 69ferrous sulfate syrup . . . . . . . . 69fesoterodine fumarate tb24 . . 66fidaxomicin . . . . . . . . . . . . . . . 39filgrastim . . . . . . . . . . . . . . . . . . . 8FINACEA . . . . . . . . . . . . . . . . . 21finasteride . . . . . . . . . . . . . . . . 66fingolimod . . . . . . . . . . . . . . . . 18FIORICET . . . . . . . . . . . . . .15, 16FIORICET W/CODEINE . . . . . 16FIORINAL . . . . . . . . . . . . . .15, 16FIORINAL W/CODEINE . . . . . 16FIRAZYR . . . . . . . . . . . . . . . . . 83FLAGYL . . . . . . . . . . . . . . .44, 50FLAREX . . . . . . . . . . . . . . . . . . 52flecainide . . . . . . . . . . . . . . . . . 10FLEET ENEMA . . . . . . . . . . . . 89FLEET PHOSPHO-SODA . . . 89FLEXERIL . . . . . . . . . . . . . . . . . 46FLOLAN . . . . . . . . . . . . . . . . . . 14FLOMAX. . . . . . . . . . . . . . . . . . 66FLONASE . . . . . . . . . . . . . . . . . 28FLORAJEN . . . . . . . . . . . .37, 89FLORANEX . . . . . . . . . . . .37, 89FLORASTOR . . . . . . . . . . .37, 89FLORINEF . . . . . . . . . . . . . . . . 29FLOVENT DISKUS . . . . . . . . . 64FLOVENT HFA . . . . . . . . . . . . 64FLOXIN . . . . . . . . . . . . . . . .27, 39FLOXIN OTIC . . . . . . . . . . . . . . 27FLUARIX QUAD . . . . . . . . . . . 85FLUBLOK . . . . . . . . . . . . . . . . . 85FLUCELVAX . . . . . . . . . . . . . . . 85fluconazole . . . . . . . . 40, 41, 50FLUCONAZOLE IN

DEXTROSE . . . . . . . . . . . . 41

fluconazole in dextrose soln . 41FLUCONAZOLE IN NACL . . . 41fluconazole in nacl soln . . . . . 41fludrocortisone . . . . . . . . . . . . 29FLULAVAL QUAD . . . . . . . . . . 85FLUMADINE . . . . . . . . . . . . . . 42fluocinolone

acetonide . . . . . . . 22, 23, 27fluocinolone acetonide

(otic) oil . . . . . . . . . . . . . . . 27fluocinonide . . . . . . . . . . . . . . . 23fluocinonide emulsified base 23fluoride . . . . . . . . . 69-71, 78, 90fluoride dental rinse . . . . . . . . 90fluorometholone . . . . . . . . . . . 52fluorometholone acetate opth

susp . . . . . . . . . . . . . . . . . . 52fluorouracil . . . . . . . . . . . . . . . . 25fluoxetine . . . . . . . . . . . . . . . . . 56FLUOXETINE HCL . . . . . . . . . 56fluoxetine HCL (pmdd) caps . 56fluoxetine HCL caps . . . . . . . . 56fluoxetine HCL tabs . . . . . . . . 56fluphenazine . . . . . . . . . . . . . . 59fluphenazine decanoate . . . . 59flurazepam . . . . . . . . . . . . . . . . 57flurbiprofen . . . . . . . . . . . . . . . 51flutamide . . . . . . . . . . . . . . . . . . 5fluticasone . . . . . . 23, 28, 64, 65fluticasone furoate . . . . . . . . . 64fluticasone HFA . . . . . . . . . . . . 64fluticasone propionate . . .23, 64fluticasone/salmeterol . . . . . . 65fluticasone/vilanterol . . . . . . . 65FLUVIRIN . . . . . . . . . . . . . . . . . 85fluvoxamine . . . . . . . . . . . . . . . 54FLUZONE HD PF . . . . . . . . . . 85FLUZONE QUAD. . . . . . . . . . . 85FLUZONE SPLT . . . . . . . . . . . 85FML . . . . . . . . . . . . . . . . . . . . . . 52FML FORTE . . . . . . . . . . . . . . . 52FML LIQUIFILM . . . . . . . . . . . . 52FOCALGIN-B . . . . . . . . . . . . . . 74FOCALIN . . . . . . . . . . . . . . . . . 55FOCALIN XR . . . . . . . . . . . . . . 55FOLBEE PLUS . . . . . . . . . . . . 78

102


Index of Covered DrugsFOLCAL DHA . . . . . . . . . . . . . 76FOLCAPS OMEGA-3

CAPSULE . . . . . . . . . . . . . 74FOLGARD OS . . . . . . . . . . . . . 70FOLGARD RX . . . . . . . . . . . . . 69folic acid . . . . . . . . 67, 69, 70, 78FOLIC ACID INJ . . . . . . . . . . . 69folic acid soln . . . . . . . . . . . . . . 69folic acid-b6-b12-d-omega

3-phytosterols cap 1 mg 69folic acid-vitamin b6-vitamin b12

tab . . . . . . . . . . . . . . . . . . . . 69FOLIVANE-OB . . . . . . . . . . . . . 77FOLIVANE-PRX DHA NF . . . . 76FOLTABS PAK PLUS DHA RE

OB + DHA PAK . . . . . . . . . 72FOLTRATE . . . . . . . . . . . . . . . . 68FORTAMET . . . . . . . . . . . . . . . 31FORTICAL . . . . . . . . . . . . . . . . 32FOSAMAX . . . . . . . . . . . . . . . . 32fosamprenavir . . . . . . . . . . . . . 43fosinopril. . . . . . . . . . . . . . . . . . . 9fosinopril/hydrochlorothiazide 9FOSTEUM . . . . . . . . . . . . . . . . 69FRAGMIN . . . . . . . . . . . . . . . . . . 7FREAMINE HBC . . . . . . . . . . . 82FREAMINE III . . . . . . . . . . . . . . 82FURADANTIN SUSP

25 MG/5 ML . . . . . . . . . . . 45furosemide . . . . . . . . . . . . . . . . 12FUROSEMIDE INJ . . . . . . . . . 12furosemide soln . . . . . . . . . . . 12FUSION PLUS . . . . . . . . . . . . . 68FUZEON . . . . . . . . . . . . . . . . . . 44

Ggabapentin . . . . . . . . . . . . . . . . 20gabapentin soln . . . . . . . . . . . 20GABITRIL . . . . . . . . . . . . . . . . . 20galantamine . . . . . . . . . . . . . . . 15ganciclovir . . . . . . . . . . . . . . . . 41GARDASIL . . . . . . . . . . . . . . . . 85GARDASIL 9 . . . . . . . . . . . . . . 85GASTROCROM . . . . . . . . . . . 86GATTEX . . . . . . . . . . . . . . . . . . 37gefitinib . . . . . . . . . . . . . . . . . . . . 4

GEL-KAM . . . . . . . . . . . . . . . . . 69gemfibrozil . . . . . . . . . . . . . . . . 12GENERESS FE . . . . . . . . . . . . 48GENGRAF . . . . . . . . . . . . . . . . . 6genistein-zinc amino acid

chelate-vitamin d cap . . . . 69GENOTROPIN . . . . . . . . . . . . . 32GENTAK . . . . . . . . . . . . . . .22, 53gentamicin . . . . . . 22, 40, 51, 53gentamicin in saline soln . . . . 40GENTAMICIN SULFATE/0.9%

SODIUM CHLORIDE . . . . 40gentamicin/prednisolone

acetate . . . . . . . . . . . . . . . . 51GENTEX ADE 28-1 MG . . . . . 73GENVOYA . . . . . . . . . . . . . . . . 44GEODON . . . . . . . . . . . . . . . . . 58GESTICARE PAK DHA . . . . . . 72GG/CODEINE . . . . . . . . . . . . . 60GG/DM CR . . . . . . . . . . . . . . . 61GILENYA . . . . . . . . . . . . . . . . . 18GILOTRIF . . . . . . . . . . . . . . . . . . 4glatiramer acetate . . . . . . . . . . 18GLATOPA . . . . . . . . . . . . . . . . . 18glecaprevir/pibrentasvir . . . . . 41GLEEVEC . . . . . . . . . . . . . . . . . 5GLEOSTINE . . . . . . . . . . . . . . . . 4glimepiride . . . . . . . . . . . . . . . . 31glipizide . . . . . . . . . . . . . . . . . . 31glipizide extended-release . . . 31glipizide-metformin . . . . . . . . . 31GLUCAGEN DIAGNOSTIC . . 30GLUCAGON . . . . . . . . . . .29, 30glucagon HCl (diagnostic)

solr . . . . . . . . . . . . . . . . . . . 29GLUCAGON HCL

DIAGNOSTIC . . . . . . . . . . 29glucagon HCL rdna (diagnostic)

solr . . . . . . . . . . . . . . . . . . . 30glucagon, human

recombinant . . . . . . . . . . . 30GLUCOPHAGE . . . . . . . . . . . . 31GLUCOPHAGE ER . . . . . . . . . 31glucose oral tablets . . . . . . . . 88

GLUCOTROL . . . . . . . . . . . . . 31GLUCOTROL XL . . . . . . . . . . . 31GLUCOVANCE . . . . . . . . . . . . 31glyburide . . . . . . . . . . . . . . . . . 31glyburide, micronized . . . . . . . 31glycerin . . . . . . . . . . . . 33, 51, 87GLYCERIN SUPPOSITORY . . 33GLYCERIN TOPICAL . . . . . . . 87glycerol phenylbutyrate . . . . . 84glycine diluent for injection . . 14glycopyrrolate . . . . . . . . . .35, 86GLYCOPYRROLATE INJ . . . . 86glycopyrrolate soln . . . . . . . . . 86GLYNASE . . . . . . . . . . . . . . . . . 31GLYSET . . . . . . . . . . . . . . . . . . 31GNP IRON . . . . . . . . . . . . . . . . 69GRANIX . . . . . . . . . . . . . . . . . . . 8GRIFULVIN V . . . . . . . . . . . . . . 41GRIS-PEG . . . . . . . . . . . . . . . . 41griseofulvin microsize . . . . . . . 41griseofulvin ultramicrosize . . . 41guaifenesin . . . . . . . . . . . . 60-64guaifenesin extended-release 61guaifenesin liqd . . . . . . . . . . . . 61guaifenesin pack . . . . . . . . . . . 62guaifenesin-codeine liquid . . . 61guaifenesin/

pseudoephedrine . . . .60, 62guaifenesin/pseudoephedrine

extended-release . . . . . . . 62guaifenesin/pseudoephedrine/

dextromethorphan . . . . . . 62guanabenz . . . . . . . . . . . . . . . . 14guanfacine . . . . . . . . . . . . . . 9, 55guanfacine ER . . . . . . . . . . . . . 55GUANIDINE HCL . . . . . . . . . . 21guanidine HCl tabs . . . . . . . . . 21GUIATUSS AC . . . . . . . . . . . . . 60GUIATUSS DAC . . . . . . . . . . . 60GYNE-LOTRIMIN . . . . . . .50, 87GYNOL II . . . . . . . . . . . . . . . . . 88

HH.P. ACTHAR. . . . . . . . . . . . . . 19HAEGARDA . . . . . . . . . . . . . . . 83

103



HALCION . . . . . . . . . . . . . . . . . 57HALDOL . . . . . . . . . . . . . . . . . . 59HALDOL DECANOATE . . . . . 59halobetasol . . . . . . . . . . . . . . . 23halobetasol propionate . . . . . 23haloperidol . . . . . . . . . . . . . . . . 59haloperidol decanoate . . . . . . 59haloperidol lactate oral conc . 59HAVRIX . . . . . . . . . . . . . . . . . . . 85HC PRAMOXINE . . . . . . . . . . . 22HECORIA . . . . . . . . . . . . . . . . . . 6HECTOROL . . . . . . . . . . . . . . . 68HEMATOGEN . . . . . . . . . . . . . 69HEMATOGEN FA . . . . . . . . . . 69HEMATRON-AF . . . . . . . . . . . 69HEMENATAL OB + DHA . . . . 73HEMETAB . . . . . . . . . . . . . . . . 71HEMLIBRA . . . . . . . . . . . . . . . . 8HEMNATAL OB . . . . . . . . . . . . 73HEMOCYTE PLUS . . . . . . . . . 69HEMOCYTE-F . . . . . . . . . . . . . 69HEMORRHOIDAL SUP -HC

25MG . . . . . . . . . . . . . . . . . 22HEP FLUSH-10 . . . . . . . . . . . . . 7heparin . . . . . . . . . . . . . . . . . . . . 7heparin (porcine) in sodium

chloride soln . . . . . . . . . . . . 7heparin sod (porcine) in d5w

soln . . . . . . . . . . . . . . . . . . . . 7heparin sodium (porcine) lock

flush soln . . . . . . . . . . . . . . . 7HEPARIN SODIUM/D5W . . . . 7HEPARIN SODIUM/NACL INJ 7HEPATAMINE . . . . . . . . . . . . . 82hepatitis a vaccine susp . . . . . 85hepatitis b vaccine

(recombinant) . . . . . . . . . . 85hepatitis b vaccine recombinant

adjuvanted . . . . . . . . . . . . . 85HEPLISAV-B . . . . . . . . . . . . . . 85HEXALEN . . . . . . . . . . . . . . . . . 4HIPREX . . . . . . . . . . . . . . . . . . 66homatropine . . . . . . . . . . .52, 62HUMALOG . . . . . . . . . . . . . . . . 30HUMALOG KWIKPEN . . . . . . 30HUMALOG MIX 50/50. . . . . . 30

HUMALOG MIX 75/25. . . . . . 30human papillomavirus (hpv)

9-valent recomb vac . . . . . 85human papillomavirus (hpv)

quadrivalent recombinant vac . . . . . . . . . . . . . . . . . . . 85

HUMATIN . . . . . . . . . . . . . . . . . 45HUMIRA . . . . . . . . . . . . . . . . . . 45HUMULIN. . . . . . . . . . 30, 31, 88HUMULIN 70/30 . . . . . . .30, 31HUMULIN 70/30 KWIKPEN . 31HUMULIN N . . . . . . . . . . . . . . . 30HUMULIN N KWIKPEN . . . . . 30HUMULIN R . . . . . . . . . . . . . . . 31HYCAMTIN . . . . . . . . . . . . . . . . 7HYCET . . . . . . . . . . . . . . . . . . . 16HYCODAN . . . . . . . . . . . . . . . . 62hydralazine. . . . . . . . . . . . . . . . 14HYDREA . . . . . . . . . . . . . . . . . . 7hydrochlorothiazide . . 9, 10, 12hydrocod polst-chlorphen polst

cap sr 12hr . . . . . . . . . . . . 62hydrocod polst-chlorphen polst

cr susp . . . . . . . . . . . . . . . . 62hydrocodone ER . . . . . . . . . . . 17hydrocodone/

acetaminophen . . . . . . . . . 16hydrocodone/acetaminophen

soln 10-325 mg/15 ml . . 16hydrocodone/homatropine . . 62hydrocodone/ibuprofen . . . . . 17HYDROCODONE/TAB

HOMATROP . . . . . . . . . . . 62hydrocortisone . . 22, 23, 25-27,

29, 36, 51, 88hydrocortisone (rectal)

cream . . . . . . . . . . . . . . . . . 22hydrocortisone acetate (rectal)

supp . . . . . . . . . . . . . . . . . . 22hydrocortisone acetate w/

pramoxine rectal cream . . 22hydrocortisone acetate w/

pramoxine rectal foam . . . 22hydrocortisone butyrate . . . . . 23hydrocortisone crm, oint . . . . 88

hydrocortisone sod succinate solr . . . . . . . . . . . . . . . . . . . 29

hydrocortisone valerate crm . 22hydrocortisone valerate oint . 22hydrocortisone/aloe . . . . . . . . 22HYDROMET SYP . . . . . . . . . . 62hydromorphone . . . . . . . . . . . 17HYDROMORPHONE HCL PF

INJ . . . . . . . . . . . . . . . . . . . 17hydromorphone HCl soln . . . 17hydroquinone cream . . . . . . . 25hydroquinone soln . . . . . . . . . 25hydroxychloroquine . . . . .44, 45hydroxyprogesterone caproate

oil . . . . . . . . . . . . . . . . . . . . 50hydroxyurea . . . . . . . . . . . . . . . . 7hydroxyzine HCl . . . . . . . . . . . 27hydroxyzine pamoate . . . . . . . 27hyoscyamine . . . . . . . . . . .35, 66hyoscyamine sulfate . . . . . . . . 35hyoscyamine sulfate extended-

release . . . . . . . . . . . . . . . . 35HYPERCARE 15% . . . . . . . . . 25HYPERLYTE-CR . . . . . . . . . . . 83HYPERSAL . . . . . . . . . . . . . . . 80HYPERTET S/D . . . . . . . . . . . 86HYPOTEARS . . . . . . . . . . . . . . 90HYTONE . . . . . . . . . . . . . . . . . 22HYTRIN . . . . . . . . . . . . . . . . 9, 66HYZAAR . . . . . . . . . . . . . . . . . 10

IIBRANCE . . . . . . . . . . . . . . . . . . 5ibrutinib . . . . . . . . . . . . . . . . . . . 5IBUDONE . . . . . . . . . . . . . . . . . 17IBUOROFEN TAB COLD/

SIN . . . . . . . . . . . . . . . . . . . 64ibuprofen . . . . . . . 15-17, 46, 90ibuprofen tabs, chew tabs, susp,

and drops . . . . . . . . . . . . . 90ICAR PEDIATRIC . . . . . . . . . . 67ICAR-C PLUS . . . . . . . . . . . . . 70icatibant . . . . . . . . . . . . . . . . . . 83ICLUSIG . . . . . . . . . . . . . . . . . . . 5idelalisib . . . . . . . . . . . . . . . . . . . 5ILARIS . . . . . . . . . . . . . . . . . . . 45

104


Index of Covered DrugsILEVRO . . . . . . . . . . . . . . . . . . 51iloperidone . . . . . . . . . . . . . . . . 58imatinib mesylate . . . . . . . . . . . 5IMBRUVICA . . . . . . . . . . . . . . . . 5IMDUR . . . . . . . . . . . . . . . . . . . 13imiglucerase solr . . . . . . . . . . . 86imipenem-cilastatin intravenous

for soln . . . . . . . . . . . . . . . . 40imipramine HCL . . . . . . . . . . . 56imipramine pamoate caps . . . 56imiquimod 5% cream . . . . . . . 25IMITREX . . . . . . . . . . . . . . . . . . 18IMITREX 4 MG AND

6 MG INJ . . . . . . . . . . . . . . 18IMODIUM A-D . . . . . . . . . .34, 89IMPAVIDO . . . . . . . . . . . . . . . . 41IMURAN . . . . . . . . . . . . . . . . 6, 45INCRELEX . . . . . . . . . . . . . . . . 32INCRUSE ELLIPTA . . . . . . . . . 65indacaterol . . . . . . . . . . . . . . . . 64indapamide . . . . . . . . . . . . . . . 12INDERAL . . . . . . . . . . . . . .11, 18INDERAL LA . . . . . . . . . . . . . . 11INDERIDE . . . . . . . . . . . . . . . . 11indinavir . . . . . . . . . . . . . . . . . . 43INDOCIN . . . . . . . . . . . . . .16, 46indomethacin . . . . . . . . . .16, 46INFANATE BALANCE

SOFTGEL . . . . . . . . . . . . . 75INFLAMASE FORTE . . . . . . . . 52influenza virus vaccine

recombinant hemagglutinin (ha) . . . . . . . . . . . . . . . . . . . 85

influenza virus vaccine split . . 85influenza virus vaccine split

high-dose pf . . . . . . . . . . . 85influenza virus vaccine split pf 85influenza virus vaccine split

quadrivalent . . . . . . . . . . . . 85influenza virus vaccine tiss-cult

subunit . . . . . . . . . . . . . . . . 85influenza virus vaccine types

a&b surface antigen . . . . . 85INFUVITE PEDIATRIC . . . . . . 70INGREZZA . . . . . . . . . . . . . . . . 21INLYTA . . . . . . . . . . . . . . . . . . . . 4

insulin (vials only) . . . . . . . . . . 88insulin aspart . . . . . . . . . . . . . . 30insulin aspart protamine &

aspart (human) supn . . . . 30insulin aspart protamine 70%/

insulin aspart 30% . . . . . . 30insulin detemir . . . . . . . . . . . . . 30insulin detemir sopn . . . . . . . . 30insulin glargine . . . . . . . . .30, 31insulin glargine 300 unit/ml . 30insulin glargine sopn . . . . . . . 30insulin glargine/lixisenatide . . 31insulin human . . . . . . . . . . . . . 30insulin isophane . . . . . . . . . . . 30insulin isophane human . . . . . 30insulin isophane human 70%/

regular 30% . . . . . . . . . . . . 30insulin isophane/regular . . . . 30insulin lisopro pro/lispro . . . . 30insulin lisopro prot/lispro . . . . 30insulin lispro . . . . . . . . . . . . . . . 30insulin lispro (human) soct . . 30insulin nph (human) (isophane)

supn . . . . . . . . . . . . . . . . . . 30insulin nph isophane & reg

(human) supn . . . . . . . . . . 31insulin regular . . . . . . . . . . . . . 31insulin syringes . . . . . . . . . . . . 84INTAL . . . . . . . . . . . . . . . . . . . . 65INTEGRA F . . . . . . . . . . . . . . . 68INTEGRA PLUS . . . . . . . . . . . 68INTELENCE . . . . . . . . . . . . . . . 42interferon alfa-2b . . . . . . . . . 6, 41interferon beta-1a . . . . . . . . . . 18interferon beta-1b kit . . . . . . . . 6INTRALIPID . . . . . . . . . . . . . . . 82INTRON A . . . . . . . . . . . . . . 6, 41INTUNIV . . . . . . . . . . . . . . . . . . 55INVANZ INJ . . . . . . . . . . . . . . . 40INVEGA SUSTENNA . . . . . . . 58INVEGA TRINZA . . . . . . . . . . . 58INVIRASE . . . . . . . . . . . . . . . . . 44INVOKANA . . . . . . . . . . . . . . . 31IODOPEN . . . . . . . . . . . . . . . . . 78IONOSOL-B/DEXTROSE 5% 82

IONOSOL-MB/DEXTROSE 5% . . . . . . . . . . . . . . . . . . . . 82

ipratropium . . . . . . . . . . . .28, 65ipratropium HFA . . . . . . . . . . . 65ipratropium nasal . . . . . . . . . . 28ipratropium/albuterol . . . . . . . 65IRENKA . . . . . . . . . . . . . . . . . . 56IRESSA . . . . . . . . . . . . . . . . . . . . 4IROMIN-G . . . . . . . . . . . . . . . . 70iron . . . 3, 48, 49, 67, 69-72, 74,

77, 78, 83, 90iron combination . . . . . . . . . . . 69iron w/vitamins tabs . . . . . . . . 70iron-docusate-b12-folic acid-c-e-

cu-biotin tab . . . . . . . . . . . . 69iron-folic acid-vit b12-vit

c-docusate sod tab . . . . . . 69iron-folic acid-vit c-vit b6-vit b12-

zinc tab . . . . . . . . . . . . . . . 70iron-vit c-vit b12-folic acid tab 70IROSPAN 24/6 . . . . . . . . . . . . 68ISENTRESS . . . . . . . . . . . . . . . 42ISENTRESS CHEWABLE . . . 42ISENTRESS HD . . . . . . . . . . . 42ISENTRESS SUSP . . . . . . . . . 42ISMO . . . . . . . . . . . . . . . . . . . . . 13isocarboxazid tabs . . . . . . . . . 56ISOLYTE-P/DEXTROSE 5% . 82ISOLYTE-S . . . . . . . . . . . . . . . . 82ISOLYTE-S PH 7.4 . . . . . . . . . 82isoniazid . . . . . . . . . . . . . . . . . . 38ISOPTO ATROPINE . . . . . . . . 52ISOPTO CARPINE . . . . . . . . . 53ISOPTO HOMATROPINE. . . . 52ISOPTO HYOSCINE . . . . . . . . 52ISORDIL . . . . . . . . . . . . . . . . . . 13ISORDIL S.L. . . . . . . . . . . . . . . 13isosorbide dinitrate . . . . . . . . . 13ISOSORBIDE DINITRATE ER 13isosorbide dinitrate extended-

release . . . . . . . . . . . . . . . . 13isosorbide mononitrate . . . . . 13isosorbide mononitrate

extended-release . . . . . . . 13isotretinoin . . . . . . . . . . . . . . . . 21itraconazole . . . . . . . . . . . . . . . 41

105



ivacaftor . . . . . . . . . . . . . . . . . . 80ivermectin . . . . . . . . . . . . .24, 37ivermectin (pediculicide) lotn 24ixazomib . . . . . . . . . . . . . . . . . . . 5

JJ-TAN D PD . . . . . . . . . . . . . . . 59JADENU . . . . . . . . . . . . . . . . . . . 8JAKAFI . . . . . . . . . . . . . . . . . . . . 5JANUMET . . . . . . . . . . . . .31, 32JANUMET XR . . . . . . . . . . . . . 32JANUVIA . . . . . . . . . . . . . . . . . 32JINTELI . . . . . . . . . . . . . . . . . . . 47JULUCA . . . . . . . . . . . . . . . . . . 44

KK-DUR 10 . . . . . . . . . . . . . . . . . 79K-DUR 20 . . . . . . . . . . . . . . . . . 79K-LOR . . . . . . . . . . . . . . . . . . . . 79K-LYTE . . . . . . . . . . . . . . . . . . . 79K-PHOS NEUTRAL . . . . . . . . . 79K-PHOS NO 2 . . . . . . . . . . . . . 79K-PHOS ORIGINAL . . . . . . . . 79K-TAB 20 . . . . . . . . . . . . . . . . . 79KABIVEN . . . . . . . . . . . . . . . . . 80KALETRA . . . . . . . . . . . . . . . . 43KALYDECO . . . . . . . . . . . . . . . 80KALYDECO GRANULES . . . . 80KAOPECTATE . . . . . . . . . . . . . 89KARBINAL ER. . . . . . . . . . . . . 59KAYEXALATE . . . . . . . . . . . . . 13KAZANO . . . . . . . . . . . . . . . . . 31kcl in dextrose & nacl inj . . . . 79kcl in nacl inj . . . . . . . . . . . . . . 79KCL/D5W/LR IV LAC RING . 79KEFLET . . . . . . . . . . . . . . . . . . 38KEFLEX . . . . . . . . . . . . . . . . . . 38KENALOG . . . . . . . . . . . . .23, 28KENALOG IN ORABASE . . . . 28KENALOG-10 INJ . . . . . . . . . . 29KEPPRA . . . . . . . . . . . . . . . . . . 20KEPPRA XR . . . . . . . . . . . . . . . 20KERLONE . . . . . . . . . . . . . . . . 10ketoconazole . . . . . . . . 23-25, 41ketoconazole (topical) foam . 24

ketoprofen . . . . . . . . . . . . .16, 46ketorolac . . . . . . . . . . . . . .16, 51ketorolac tromethamine . . . . . 16KETOROLAC TROMETHAMINE

INJ . . . . . . . . . . . . . . . . . . . 16ketorolac tromethamine soln . 16ketotifen . . . . . . . . . . . . . . . . . . 51KEVZARA . . . . . . . . . . . . . . . . 45KIMONO. . . . . . . . . . . . . . . . . . 88KINERET . . . . . . . . . . . . . . . . . 45KIONEX . . . . . . . . . . . . . . . . . . 14KLONOPIN . . . . . . . . . . . .19, 54KLOR-CON 10 . . . . . . . . . . . . 79KLOR-CON 8 . . . . . . . . . . . . . 79KLOR-CON M15 . . . . . . . . . . . 79KORLYM . . . . . . . . . . . . . . . . . 33KUVAN . . . . . . . . . . . . . . . . . . . 33KUVAN POWDER FOR

SOLUTION . . . . . . . . . . . . 33

LL-CYSTEINE HCL . . . . . . . . . . 80L-METHYLFOLATE . . . . . .70, 71l-methylfolate tabs . . . . . . . . . . 70l-methylfolate w/vit b12-vit b6-vit

b2 tab 6-1-50-5 mg . . . . . 70l-methylfolate-methylcobalamin-

acetylcyst tab 6-2-600 mg . . . . . . . . . . . . 70

labetalol . . . . . . . . . . . . . . . . . . 10LAC-HYDRIN . . . . . . . . . . . . . . 25lacosamide . . . . . . . . . . . . . . . 20lacosamide soln . . . . . . . . . . . 20lactated ringer’s (irrigation)

soln . . . . . . . . . . . . . . . . . . . 83lactated ringer’s solution . . . . 82LACTATED RINGERS . . .82, 83LACTATED RINGERS

IRRIGATION . . . . . . . . . . . 83LACTIC ACID E . . . . . . . . . . . . 25lactic acid w/vitamin E cream

10%-3500 unit/30gm . . . 25LACTINEX . . . . . . . . . . . . .37, 89LACTINOL . . . . . . . . . . . . . . . . 25lactulose . . . . . . . . . . . . . . . . . . 33LAMICTAL . . . . . . . . . . . . . . . . 20

LAMICTAL CD CHEW TAB . . 20LAMICTAL ODT . . . . . . . . . . . 20LAMICTAL STARTER KIT . . . 20LAMISIL . . . . . . . . . . . . . . .24, 41LAMISIL AT . . . . . . . . . . . . . . . 24lamivudine . . . . . . . . . 41, 43, 44lamivudine/zidovudine . . . . . . 43lamotrigine . . . . . . . . . . . . . . . . 20lamotrigine chew dispersable

tab . . . . . . . . . . . . . . . . . . . . 20lamotrigine ODT . . . . . . . . . . . 20lamotrigine starter kit . . . . . . . 20lancets . . . . . . . . . . . . . . . . . . . 84LANOXIN . . . . . . . . . . . . . . . . . 10lansoprazole . . . . . . . . . . . . . . 35lansoprazole delayed-release 35LANTUS . . . . . . . . . . . . . . . . . . 30LANTUS SOLOSTAR . . . . . . . 30lapatinib ditosylate . . . . . . . . . . 5LARIAM . . . . . . . . . . . . . . . . . . 44LASIX . . . . . . . . . . . . . . . . . . . . 12latanoprost . . . . . . . . . . . . . . . . 53LATUDA . . . . . . . . . . . . . . . . . . 58laxative enemas . . . . . . . . . . . 89laxatives . . . . . . . . . . . . 2, 33, 89leflunomide . . . . . . . . . . . . . . . 45lenalidomide caps . . . . . . . . . . 6lenvatinib . . . . . . . . . . . . . . . . . . 5LENVIMA . . . . . . . . . . . . . . . . . . 5LETAIRIS . . . . . . . . . . . . . . . . . 13letrozole . . . . . . . . . . . . . . . . . . . 5leucovorin . . . . . . . . . . . . . . . . . 5LEUKERAN . . . . . . . . . . . . . . . . 4LEUKINE . . . . . . . . . . . . . . . . . . 8leuprolide . . . . . . . . . . . . . . . . 5, 6leuprolide acetate (cpp) (3

month) kit . . . . . . . . . . . . . . . 6levalbuterol HCl . . . . . . . . . . . . 65LEVAQUIN . . . . . . . . . . . . . . . . 39LEVAQUIN INJ . . . . . . . . . . . . 39LEVEMIR . . . . . . . . . . . . . . . . . 30LEVEMIR FLEXTOUCH . . . . . 30levetiracetam . . . . . . . . . . . . . . 20levetiracetam oral solution . . . 20levetiracetam tb24 . . . . . . . . . 20levobunolol . . . . . . . . . . . . . . . 52

106


Index of Covered Drugslevocarnitine (metabolic

modifiers) oral solution . . 86levocarnitine (metabolic

modifiers) tabs . . . . . . . . . 86levocetirizine . . . . . . . . . . . . . . 27levofloxacin . . . . . . . . . . . . . . . 39levofloxacin in d5w soln . . . . . 39levomefolate glucosamine

tabs . . . . . . . . . . . . . . . . . . 48levonorgestrel . . . . . . . . . . 47-49levonorgestrel-ethinyl

estradiol . . . . . . . . . . . . . . . 48levonorgestrel/EE . . . . . . . 47-49levothyroxine . . . . . . . . . . . . . . 32LEVOTHYROXINE

SODIUM IV . . . . . . . . . . . . 32levothyroxine sodium solr iv . 32LEVOXYL . . . . . . . . . . . . . . . . . 32LEVSIN . . . . . . . . . . . . . . . . . . . 35LEVSINEX . . . . . . . . . . . . . . . . 35LEXAPRO . . . . . . . . . . . . . . . . 56LEXIVA . . . . . . . . . . . . . . . . . . . 43LEXUSS 210 . . . . . . . . . . . . . . 60LIBRAX . . . . . . . . . . . . . . . . . . . 34LIBRIUM . . . . . . . . . . . . . . . . . . 54LIDAMANTEL . . . . . . . . . . . . . 25LIDEX . . . . . . . . . . . . . . . . . . . . 23LIDEX E . . . . . . . . . . . . . . . . . . 23lidocaine . . . . . . . . 25, 26, 28, 84LIDOCAINE HCL . . . . 25, 26, 84lidocaine HCl (local anesth.)

soln . . . . . . . . . . . . . . . . . . . 84LIDOCAINE HCL MDV . . . . . . 84LIDOCAINE HCL/

DEXTROSE IV . . . . . . . . . . 84LIDOCAINE HCL/

HYDROCORTISONE ACETATE . . . . . . . . . . . . . . 26

LIDOCAINE HCL/HYDROCORTISONE ACETATE WITH ALOE . . . 26

lidocaine in dextrose iv soln . 84lidocaine inj w/epinephrine . . 84lidocaine patch . . . . . . . . . . . . 26lidocaine viscous . . . . . . . . . . 28

LIDOCAINE/EPINEPHRINE . 84lidocaine/hydrocortisone

acetate rectal cream kit . . 26lidocaine/hydrocortisone

acetate rectal gel . . . . . . . 26lidocaine/prilocaine . . . . . . . . 26lidocaine/tetracaine cream . . 26LIDODERM . . . . . . . . . . . . . . . 26LIFESTYLES . . . . . . . . . . . . . . 88lifitegrast . . . . . . . . . . . . . . . . . . 53LIMBITROL . . . . . . . . . . . . . . . 59linaclotide . . . . . . . . . . . . . . . . . 33linagliptin . . . . . . . . . . . . . . . . . 31linezolid . . . . . . . . . . . . . . . . . . 44LINZESS . . . . . . . . . . . . . . . . . . 33liothyronine . . . . . . . . . . . . . . . 33liotrix . . . . . . . . . . . . . . . . . . . . . 33LIPITOR . . . . . . . . . . . . . . . . . . 13LIPOSYN III . . . . . . . . . . . . . . . 82lisdexamfetamine . . . . . . . . . . 55lisdexamfetamine chewable

tab . . . . . . . . . . . . . . . . . . . . 55lisinopril . . . . . . . . . . . . . . .9, 123lisinopril/hydrochlorothiazide . 9lithium carbonate . . . . . . . . . . 56lithium carbonate extended-

release . . . . . . . . . . . . . . . . 56LITHOBID . . . . . . . . . . . . . . . . . 56lixisenatide . . . . . . . . . . . . .31, 32LMX-4 . . . . . . . . . . . . . . . . . . . . 26LO LOESTRIN FE . . . . . . . . . . 48LO MINASTRIN PAK FE . . . . . 47LO/OVRAL . . . . . . . . . . . . . . . . 48LOCOID . . . . . . . . . . . . . . . . . . 23LODINE . . . . . . . . . . . . . . .15, 46LOESTRIN 1/20 . . . . . . . . . . . 48LOESTRIN 1.5/30 . . . . . . . . . 48LOESTRIN FE 1/20 . . . . . . . . 48LOESTRIN FE 1.5/30 . . . . . . . 48LOFIBRA . . . . . . . . . . . . . . . . . 12LOHIST-D . . . . . . . . . . . . . . . . . 60LOMEDIA 24 FE . . . . . . . . . . . 48LOMOTIL . . . . . . . . . . . . . . . . . 34lomustine . . . . . . . . . . . . . . . . . . 4LONITEN . . . . . . . . . . . . . . . . . 14LONSURF . . . . . . . . . . . . . . . . . 4

loperamide . . . . . . . . . . . . . . . . 34LOPID . . . . . . . . . . . . . . . . . . . . 12lopinavir/ritonavir . . . . . . . . . . 43LOPRESS HCT . . . . . . . . . . . . 10LOPRESSOR . . . . . . . . . . . . . . 10loratadine . . . . . . . 27, 28, 62, 88loratadine & pseudoephedrine

SR 24hr . . . . . . . . . . . . . . . 62loratadine/

pseudoephedrine 28, 62, 88loratadine/pseudoephedrine

extended-release . . . . . . . 28lorazepam . . . . . . . . . . . . . . . . 54lorazepam conc . . . . . . . . . . . 54LORAZEPAM INJ . . . . . . . . . . 54lorazepam inj soln . . . . . . . . . . 54LORAZEPAM INTENSOL . . . 54LORCET . . . . . . . . . . . . . . . . . . 16LORTAB . . . . . . . . . . . . . . . . . . 16LORTAB ELIXIR . . . . . . . . . . . 16LORTUSS EX . . . . . . . . . . . . . 64losartan . . . . . . . . . . . . . . . . 9, 10losartan/HCTZ . . . . . . . . . . . . 10LOSEASONIQUE . . . . . . . . . . 48LOTEMAX . . . . . . . . . . . . . . . . 52LOTENSIN . . . . . . . . . . . . . . . 8, 9LOTENSIN HCT . . . . . . . . . . . . 9loteprednol etabonate . . . . . . 52loteprednol etabonate-

tobramycin . . . . . . . . . . . . . 51LOTREL . . . . . . . . . . . . . . . . . . 11LOTRIMIN AF . . . . . . . . . .23, 87LOTRISONE . . . . . . . . . . . . . . . 23LOTRONEX . . . . . . . . . . . . . . . 34lovastatin . . . . . . . . . . . . . . . . . 13LOVAZA . . . . . . . . . . . . . . . . . . 13LOVENOX . . . . . . . . . . . . . . . . . 7loxapine . . . . . . . . . . . . . . . . . . 59LOXITANE . . . . . . . . . . . . . . . . 59LOZOL . . . . . . . . . . . . . . . . . . . 12LUDIOMIL . . . . . . . . . . . . . . . . 57LUFYLLIN . . . . . . . . . . . . . . . . 65lumacaftor/ivacaftor . . . . . . . . 80LUPRON . . . . . . . . . . . . . . . . 5, 6LUPRON DEPOT . . . . . . . . . . . 5LUPRON DEPOT 6-MONTH . . 5

107



LUPRON DEPOT-PED . . . . . . . 6lurasidone HCL tabs. . . . . . . . 58LURIDE . . . . . . . . . . . . . . . . . . . 69LURIDE LOZI-TABS. . . . . . . . . 69LUSTRA . . . . . . . . . . . . . . . . . . 25LUVOX . . . . . . . . . . . . . . . . . . . 54LYNPARZA . . . . . . . . . . . . . . . . 7LYRICA . . . . . . . . . . . . . . . . . . . 20LYRICA SOLUTION . . . . . . . . 20LYSODREN . . . . . . . . . . . . . . . . 7LYSTEDA . . . . . . . . . . . . . . . . . 51

MM-CLEAR WC . . . . . . . . . . . . . 60M-END DM LIQ . . . . . . . . . . . . 63M-END MAX D . . . . . . . . . . . . 64M-END PE . . . . . . . . . . . . . . . . 62M-END WC . . . . . . . . . . . . . . . 63M-M-R II . . . . . . . . . . . . . . . . . . 85MAALOX . . . . . . . . . . . . . .34, 89MAALOX LIQUID . . . . . . . . . . 89macitentan . . . . . . . . . . . . . . . . 13MACNATAL CN DHA

SOFTGEL . . . . . . . . . . . . . 75MACROBID . . . . . . . . . . . . . . . 45MACRODANTIN . . . . . . . . . . . 45mafenide acetate cream . . . . 22MAG-OX . . . . . . . . . . . . . . .70, 90MAGNESIUM CHLORIDE

INJ . . . . . . . . . . . . . . . . . . . 70magnesium chloride inj soln . 70magnesium citrate soln . . . . . 33magnesium oxide . . . . . . .70, 90MAGNESIUM SULFATE INJ . 70magnesium sulfate inj soln . . 70MAKENA . . . . . . . . . . . . . . . . . 50malathion . . . . . . . . . . . . . . . . . 24manganese chloride inj soln . 70MANGANESE TRACE METAL

INJ . . . . . . . . . . . . . . . . . . . 70MAPAP COLD TAB . . . . . . . . 63maprotiline . . . . . . . . . . . . . . . . 57MAR-COF BP . . . . . . . . . . . . . 63MAR-COF CG

EXPECTORANT . . . . . . . . 61

maraviroc . . . . . . . . . . . . . . . . . 44MARCAINE . . . . . . . . . . . . . . . 84MARINOL . . . . . . . . . . . . . . . . . 34MARNATAL-F . . . . . . . . . . . . . . 78MARPLAN . . . . . . . . . . . . . . . . 56MATULANE . . . . . . . . . . . . . . . . 7MATZIM LA, CARDIZEM LA . 11MAVIK . . . . . . . . . . . . . . . . . . . . . 9MAVYRET . . . . . . . . . . . . . . . . 41MAXALT/MAXALT MLT . . . . . 18MAXIDEX . . . . . . . . . . . . . . . . . 52MAXITROL. . . . . . . . . . . . . . . . 51MAXZIDE . . . . . . . . . . . . . . . . . 12measles, mumps & rubella virus

vaccines for inj . . . . . . . . . 85mecasermin . . . . . . . . . . . . . . . 32meclizine . . . . . . . . . . . . . .34, 89MEDROL . . . . . . . . . . . . . . . . . 29medroxyprogesterone

acetate . . . . . . . . . . . . .47, 50medroxyprogesterone acetate

(contraceptive) susp . . . . . 47mefloquine . . . . . . . . . . . . . . . . 44MEFOXIN . . . . . . . . . . . . . . . . . 38MEGACE . . . . . . . . . . . . . . . . . . 6megestrol acetate . . . . . . . . . . . 6MEKINIST . . . . . . . . . . . . . . . . . 5MELLARIL . . . . . . . . . . . . . . . . 59meloxicam . . . . . . . . . . . . .16, 46melphalan . . . . . . . . . . . . . . . . . 4MELQUIN 3 . . . . . . . . . . . . . . . 25memantine . . . . . . . . . . . . . . . . 15MENACTRA . . . . . . . . . . . . . . . 86MENEST . . . . . . . . . . . . . . . . . 49meningococcal (a, c, y, and

w-135) . . . . . . . . . . . . .85, 86meningococcal (a, c, y, and

w-135) conjugate vaccine . . . . . . . . . . . . . . . . 86

meningococcal (a, c, y, and w-135) oligo conj vac for inj . . . . . . . . . . . . . . . . . . 86

MENOMUNE . . . . . . . . . . . . . . 85MENVEO . . . . . . . . . . . . . . . . . 86meperidine . . . . . . . . . . . . . . . . 17MEPHYTON . . . . . . . . . . . . . . 71

MEPIVACAINE HCL INJ . . . . . 84mepivacaine HCl inj soln . . . . 84MEPRON . . . . . . . . . . . . . . . . . 41mercaptopurine . . . . . . . . . . . . . 4meropenem solr . . . . . . . . . . . 40MERREM . . . . . . . . . . . . . . . . . 40mesalamine . . . . . . . . . . . . . . . 36mesalamine

extended-release . . . . . . . 36mesalamine supp . . . . . . . . . . 36mesna . . . . . . . . . . . . . . . . . . . . . 7MESNEX . . . . . . . . . . . . . . . . . . 7MESTINON . . . . . . . . . . . . . . . 18MESTINON TIMESPAN . . . . . 18METADATE CD . . . . . . . . . . . . 55METADATE ER . . . . . . . . . . . . 55METAGLIP . . . . . . . . . . . . . . . . 31METAMUCIL . . . . . . . . . . . . . . 89metaproterenol . . . . . . . . . . . . 65METAPROTERENOL SYRUP 65metformin . . . . . . . . . . . . . . . . . 31metformin ER . . . . . . . . . . . . . 31metformin HCL tb24 . . . . . . . 31metformin/glyburide . . . . . . . . 31methazolamide . . . . . . . . . . . . 53methenamine . . . . . . . . . . . . . 66methenamine hippurate . . . . . 66METHENAMINE

MANDELATE . . . . . . . . . . 66methenamine mandelate

tabs . . . . . . . . . . . . . . . . . . . 66METHERGINE . . . . . . . . . .33, 51methimazole . . . . . . . . . . . . . . 33methocarbamol . . . . . . . . . . . . 47methotrexate . . . . . . . . . . . . . . 45methoxsalen . . . . . . . . . . . . . . 24methoxsalen (topical) lotion. . 24METHSCOPOLAMINE

BROMIDE . . . . . . . . . . . . . 35methscopolamine bromide

tabs . . . . . . . . . . . . . . . . . . . 35methsuximide . . . . . . . . . . . . . 20METHYCLOTHIAZIDE . . . . . . 12methyclothiazide tabs . . . . . . 12

108


Index of Covered Drugsmethyldopa . . . . . . . . . . . . . . . 14methyldopa/HCTZ . . . . . . . . . 14methylene blue . . . . . . . . . . . . 66methylergonovine . . . . . . .33, 51METHYLIN . . . . . . . . . . . . . . . . 55methylphenidate . . . . . . . . . . . 55methylphenidate extended-

release . . . . . . . . . . . . . . . . 55methylphenidate HCL chew . 55methylphenidate HCL ER

24hr . . . . . . . . . . . . . . . . . . 55methylphenidate HCL oral

susr . . . . . . . . . . . . . . . . . . . 55methylphenidate patch. . . . . . 55methylprednisolone . . . . . . . . 29methylprednisolone acetate

susp . . . . . . . . . . . . . . . . . . 29methylprednisolone sod succ

solr . . . . . . . . . . . . . . . . . . . 29metipranolol . . . . . . . . . . . . . . . 52METIPRANOLOL OTH SOLN 52metipranolol soln . . . . . . . . . . 52metoclopramide . . . . . . . . . . . 34metolazone . . . . . . . . . . . . . . . 12metoprolol . . . . . . . . . . . . . . . . 10metoprolol &

hydrochlorothiazide tab . . 10metoprolol succinate . . . . . . . 10METROCREAM . . . . . . . . . . . 24METROGEL . . . . . . . . . . . .24, 50METROGEL 1% . . . . . . . . . . . 50METROGEL-VAGINAL . . . . . . 50METROLOTION . . . . . . . . . . . 24metronidazole . . . . . . 24, 44, 50METRONIDAZOLE IN NACL

0.79% . . . . . . . . . . . . . . . . . 44metronidazole in nacl soln . . . 44MEVACOR . . . . . . . . . . . . . . . . 13mexiletine . . . . . . . . . . . . . . . . . 10MEXITIL . . . . . . . . . . . . . . . . . . 10MIACALCIN . . . . . . . . . . . . . . . 32MICARDIS . . . . . . . . . . . . . . . . . 9MICARDIS HCT . . . . . . . . . . . . . 9MICATIN . . . . . . . . . . . . . . .24, 87miconazole . . . . . . . . 24, 50, 87MICONAZOLE 1 . . . . . . . . . . . 24

miconazole crm . . . . . . . . . . . 87miconazole nitrate vaginal kit 24MICRO-K 10 . . . . . . . . . . . . . . 79MICRO-K 8 . . . . . . . . . . . . . . . 79MICRONASE . . . . . . . . . . . . . . 31MICROZIDE . . . . . . . . . . . . . . . 12MIDAMOR . . . . . . . . . . . . . . . . 12midodrine . . . . . . . . . . . . . . . . . 14midostaurin . . . . . . . . . . . . . . . . 5mifepristone . . . . . . . . . . . . . . . 33MIGERGOT

SUPPOSITORIES . . . . . . . 17miglitol . . . . . . . . . . . . . . . . . . . 31miglustat caps . . . . . . . . . . . . . 86MILRINONE IN

DEXTROSE IV . . . . . . . . . . 14milrinone in dextrose iv soln . 14MILRINONE LACTATE IV . . . 14milrinone lactate soln . . . . . . . 14miltefosine . . . . . . . . . . . . . . . . 41MINASTRIN 24 FE . . . . . . . . . 48MINIPRESS . . . . . . . . . . . . . . . . 9MINOCIN . . . . . . . . . . . . . . . . . 40minocycline . . . . . . . . . . . . . . . 40minoxidil . . . . . . . . . . . . . . . . . . 14MINUTUSS DR SYP . . . . . . . . 63MIRALAX . . . . . . . . . . . . . . . . . 34MIRAPEX . . . . . . . . . . . . . . . . . 19MIRAPEX ER . . . . . . . . . . . . . . 19MIRCETTE . . . . . . . . . . . . . . . . 47mirtazapine . . . . . . . . . . . . . . . 57MIRVASO . . . . . . . . . . . . . . . . . 24misoprostol . . . . . . . . . . . .37, 46MITIGARE . . . . . . . . . . . . .17, 46mitotane . . . . . . . . . . . . . . . . . . . 7MOBIC . . . . . . . . . . . . . . . .16, 46MODICON . . . . . . . . . . . . . . . . 48MODURETIC . . . . . . . . . . . . . . 12mometasone . . . . 23, 28, 64, 65mometasone furoate . . . .23, 28mometasone furoate (nasal)

susp . . . . . . . . . . . . . . . . . . 28mometasone inhalation . . . . . 64mometasone/formoterol . . . . 65MONISTAT . . . . . . . . . . . . .50, 87MONISTAT 3 . . . . . . . . . . . . . . 50

MONISTAT-DERM . . . . . . . . . . 24MONOPRIL . . . . . . . . . . . . . . . . 9MONOPRIL-HCT . . . . . . . . . . . . 9montelukast . . . . . . . . . . . . . . . 65morphine . . . . . . . . . . . . . . . . . 17morphine extended-release . . 17MORPHINE SULFATE IV . . . . 17morphine sulfate iv soln . . . . . 17MOTRIN . . . . . . . . . . . 16, 46, 90MOTRIN IB . . . . . . . . . . . . . . . 90MOVANTIK . . . . . . . . . . . . . . . 37MOXEZA . . . . . . . . . . . . . . . . . 53moxifloxacin HCL (ophth)

soln . . . . . . . . . . . . . . . . . . . 53MOZOBIL . . . . . . . . . . . . . . . . . . 8MS CONTIN . . . . . . . . . . . . . . . 17MSIR . . . . . . . . . . . . . . . . . . . . . 17MUCINEX . . . . . . . . . . . . . .61, 62MUCINEX D . . . . . . . . . . . . . . . 62MUCINEX DM . . . . . . . . . . . . . 61MUCINEX FOR KIDS . . . . . . . 62MUCOMYST . . . . . . . . . . . . . . 80MULTI SYMPTOM TAB COLD

RLF . . . . . . . . . . . . . . . . . . . 64MULTICHEW CHW . . . . . . . . . 70multiple vitamin inj . . . . . . . . . 70multiple vitamins w/calcium

misc . . . . . . . . . . . . . . . . . . 70multiple vitamins w/minerals &

calcium-folic acid tabs . . . 70multiple vitamins w/minerals &

folic acid . . . . . . . . . . . . . . . 70multiple vitamins w/minerals &

folic acid chew . . . . . . . . . 70MULTITRACE-4 . . . . . . . . . . . . 78MULTITRACE-4

CONCENTRATE . . . . . . . . 78MULTITRACE-4 NEONATAL . 78MULTITRACE-4 PEDIATRIC . 78MULTITRACE-5 . . . . . . . . . . . . 78MULTITRACE-5

CONCENTRATE . . . . . . . . 78multivitamins/fluoride/±iron . 70multivitamins/minerals . . .70, 72mupirocin . . . . . . . . . . . . . . . . . 22

109



mupirocin calcium oint . . . . . 22MURINE . . . . . . . . . . . . . . . . . . 90MURO 128 . . . . . . . . . . . . . . . 54MYAMBUTOL . . . . . . . . . . . . . 37MYCELEX . . . . . . . . . . . . .23, 40MYCOBUTIN . . . . . . . . . . . . . . 38mycophenolate mofetil . . . . . . . 6mycophenolate mofetil HCl

solr . . . . . . . . . . . . . . . . . . . . 6mycophenolate sodium . . . . . . 6MYCOSTATIN . . . . . . . . . .24, 41MYFORTIC. . . . . . . . . . . . . . . . . 6MYLANTA . . . . . . . . . . . . .34, 89MYLANTA LIQUID . . . . . . . . . 89MYLERAN . . . . . . . . . . . . . . . . . 4MYLICON . . . . . . . . . . . . . . . . . 89MYORISAN . . . . . . . . . . . . . . . 21MYSOLINE . . . . . . . . . . . . . . . . 20MYTESI . . . . . . . . . . . . . . . . . . 34

Nnabumetone . . . . . . . . . . . . . . 16NADOLOL . . . . . . . . . . . . . . . . 11nadolol tabs . . . . . . . . . . . . . . . 11naloxegol . . . . . . . . . . . . . . . . . 37naloxone . . . . . . . . . . . . . . .17, 57NALOXONE INJ . . . . . . . . . . . 57naltrexone . . . . . . . . . . . . .54, 57NAMENDA . . . . . . . . . . . . . . . . 15naphazoline HCL . . . . . . . . . . 51naphazoline/glycerin . . . . . . . 51naphazoline/zinc sulfate . . . . 51NAPHCON A . . . . . . . . . . . . . . 90NAPRELAN . . . . . . . . . . . . . . . 46NAPROSYN . . . . . . . . . . . .16, 46naproxen . . . . . . . . . . . . . .16, 46naproxen delayed release 16, 46naproxen sodium . . . . . . .16, 46naproxen sodium tb24 . . . . . . 46naratriptan . . . . . . . . . . . . . . . . 18NARCAN NASAL SPRAY . . . 57NASACORT ALLERGY 24

HOUR . . . . . . . . . . . . . . . . . 28nasal sprays . . . . . . . . . . . . . . . 88NASALCROM . . . . . . . . . . . . . 28NASONEX . . . . . . . . . . . . . . . . 28

NATACYN . . . . . . . . . . . . . . . . . 54natalizumab conc . . . . . . . . . . 37NATALVIT . . . . . . . . . . . . . . . . . 74natamycin susp . . . . . . . . . . . . 54NATAZIA . . . . . . . . . . . . . . . . . . 47nateglinide . . . . . . . . . . . . . . . . 31NATROBA . . . . . . . . . . . . . . . . 24NAVANE . . . . . . . . . . . . . . . . . . 59NEBUPENT . . . . . . . . . . . . . . . 41NEBUSAL . . . . . . . . . . . . . . . . 80NEEVO DHA . . . . . . . . . . . . . . 77nelfinavir . . . . . . . . . . . . . . . . . . 43NEO-SYNEPHRINE . . . . .28, 88neomycin sulfate . . . . . . . . . . . 44neomycin/bacitracin/

polymyxin . . . . . . . . . . . . . . 53neomycin/polymyxin b

gu soln . . . . . . . . . . . . . . . . 66neomycin/polymyxin B/

bacitracin . . . . . . . . . . . . . . 22neomycin/polymyxin B/

dexamethasone . . . . . . . . 51neomycin/polymyxin B/

gramicidin . . . . . . . . . . . . . 53neomycin/polymyxin B/

hydrocortisone . . . . . .27, 51neomycin/polymyxin-HC cream

0.5% . . . . . . . . . . . . . . . . . . 22NEORAL . . . . . . . . . . . . . . . . . . 6NEOSPORIN . . . . 22, 53, 66, 88NEOSPORIN GU IRRIGANT . 66nepafenac susp . . . . . . . . . . . . 51NEPHPLEX RX . . . . . . . . . . . . 67NEPHRAMINE. . . . . . . . . . . . . 82NEPHROCAPS . . . . . . . . . . . . 78NEPHRON FA . . . . . . . . . . . . . 69NEPTAZANE . . . . . . . . . . . . . . 53NESACAINE-MPF . . . . . . . . . . 84NESINA . . . . . . . . . . . . . . . . . . 31NESTABS ABC . . . . . . . . . . . . 73NESTABS DHA . . . . . . . . . . . . 74NEULASTA . . . . . . . . . . . . . . . . 8NEUPOGEN . . . . . . . . . . . . . . . 8NEURONTIN . . . . . . . . . . . . . . 20

NEUTROGENA OIL FREE ACNE WASH . . . . . . . . . . . 21

nevirapine . . . . . . . . . . . . . . . . 42nevirapine ER . . . . . . . . . . . . . 42NEXA PLUS SOFTGEL . . . . . 76NEXAVAR . . . . . . . . . . . . . . . . . 5NEXIUM 24HR OTC . . . . . . . . 34NEXIUM DELAYED-RELEASE

PACKET . . . . . . . . . . . . . . . 35niacin . . . . . . . . . . . . . . . . . . . . 13niacin extended-release . . . . . 13niacinamide w/zinc-copper &

l-methylfolate tabs 70niacinamide w/zinc-copper-

methylfolate-se-cr tabs . . 71NIACOR . . . . . . . . . . . . . . . . . . 13NIASPAN . . . . . . . . . . . . . . . . . 13nicardipine . . . . . . . . . . . . . . . . 11NICODERM CQ . . . . . . . .58, 90NICOMIDE . . . . . . . . . . . . .70, 71NICORETTE OTC . . . . . . . . . . 58nicotine . . . . . . . . . . . . . . . .58, 90NICOTINE GUM . . . . . . . . . . . 90nicotine kit . . . . . . . . . . . . . . . . 58nicotine polacrilex gum . . . . . 58nicotine polacrilex lozenge . . 58NICOTINE TRANSDERMAL

SYSTEM . . . . . . . . . . . . . . . 58NICOTROL . . . . . . . . . . . . . . . 90nifedipine . . . . . . . . . . . . . . . . . 11nifedipine extended-release . 11nilotinib . . . . . . . . . . . . . . . . . . . . 5nimodipine . . . . . . . . . . . . . . . . 11nimodipine oral soln . . . . . . . . 11NIMOTOP. . . . . . . . . . . . . . . . . 11NINLARO . . . . . . . . . . . . . . . . . . 5nintedanib . . . . . . . . . . . . . . . . 83niraparib . . . . . . . . . . . . . . . . . . . 7nitazoxanide suspension . . . . 41nitazoxanide tablet . . . . . . . . . 41nitisinone . . . . . . . . . . . . . . . . . 33NITREK . . . . . . . . . . . . . . . . . . 13NITRO-BID . . . . . . . . . . . . . . . . 13NITRO-DUR . . . . . . . . . . . . . . . 13nitrofurantoin

extended-release . . . . . . . 45

110


Index of Covered Drugsnitrofurantoin macrocrystals . 45nitrofurantoin susp . . . . . . . . . 45nitroglycerin . . . . . . . . . . . .13, 26nitroglycerin cpcr . . . . . . . . . . 13NITROGLYCERIN ER . . . . . . . 13NITROLINGUAL . . . . . . . . . . . 13NITROSTAT . . . . . . . . . . . . . . . 13NITYR . . . . . . . . . . . . . . . . . . . . 33NIX 24, 89NIX CREME RINSE . . . . . . . . . 24NIZORAL . . . . . . . . . . 23, 25, 41NIZORAL SHAMPOO. . . . . . . 25NOLVADEX . . . . . . . . . . . . . . . . 5NORCO . . . . . . . . . . . . . . . . . . 16NORDETTE . . . . . . . . . . . . . . . 48norelgestromin/EE . . . . . . . . . 49norethin-eth estradiol-fe . . . . . 48norethindrone . . . . . . . . . . 47-50norethindrone & ethinyl

estradiol-fe chew tab . . . . 48norethindrone ace & ethinyl

estradiol-fe . . . . . . . . . . . . . 48norethindrone ace-eth estradiol-

fe chew tab . . . . . . . . . . . . 48norethindrone acetate . . . 48-50norethindrone acetate-ethinyl

estradiol tab . . . . . . . . . . . . 47norethindrone acetate/

EE . . . . . . . . . . . . . . . . .48, 49norethindrone acetate/EE/

iron . . . . . . . . . . . . . . . .48, 49norethindrone/EE . . . . . . . 47-49norethindrone/ethinyl estradiol/

ferrous fumarate . . . . . . . . 47norethindrone/ME . . . . . . . . . 49NORFLEX . . . . . . . . . . . . . . . . 47norgestimate-eth estrad . . . . . 49norgestimate/EE . . . . . . . .48, 49norgestrel/EE . . . . . . . . . .48, 49NORMOSOL-M IN D5W . . . . . 82NORMOSOL-R . . . . . . . . . . . . 82NORMOSOL-R IN D5W . . . . . 82NORPACE . . . . . . . . . . . . . . . . 10NORPACE CR . . . . . . . . . . . . . 10NORPRAMIN . . . . . . . . . . . . . . 56nortriptyline . . . . . . . . . . . . . . . 56

NORVASC . . . . . . . . . . . . . . . . 11NORVIR . . . . . . . . . . . . . . . . . . 44NOVAFERRUM 50 . . . . . . . . . 71NOVAFERRUM PEDIATRIC

DROPS. . . . . . . . . . . . . . . . 71NOVAREL . . . . . . . . . . . . . . . . 50NOVOLIN . . . . . . . . . . . . . .30, 88NOVOLIN 70/30 . . . . . . . . . . . 30NOVOLIN N . . . . . . . . . . . . . . . 30NOVOLIN R . . . . . . . . . . . . . . . 30NOVOLOG . . . . . . . . . . . . . . . . 30NOVOLOG FLEXPEN . . . . . . . 30NOVOLOG MIX 70/30 . . . . . . 30NOVOLOG MIX 70/30

PREFILLED FLEXPEN . . . 30NOVOLOG PENFILL . . . . . . . 30NUEDEXTA . . . . . . . . . . . . . . . 59NULYTELY . . . . . . . . . . . . . . . . 34NUTRILYTE . . . . . . . . . . . . . . . 82nutritional supplements caps 71NUTROPIN AQ NUSPIN . . . . 32NUVARING . . . . . . . . . . . . . . . 47NUVIGIL . . . . . . . . . . . . . . . . . . 15NYMALIZE . . . . . . . . . . . . . . . . 11nystatin . . . . . . . . . . . . . . . .24, 41NYTOL QUICK CAPS . . . . . . . 57

OOB COMPLETE . . . . 72, 74, 76OB COMPLETE ONE . . . . . . . 76OB COMPLETE PETITE . . . . 76OB COMPLETE PREMIER . . 74OB COMPLETE/DHA . . . . . . 72OCEAN NASAL SPRAY . . . . . 28octreotide . . . . . . . . . . . . . . . . . . 7OCUFEN . . . . . . . . . . . . . . . . . 51OCUFLOX . . . . . . . . . . . . . . . . 53ODEFSEY. . . . . . . . . . . . . . . . . 43ODOMZO . . . . . . . . . . . . . . . . . . 7OFEV . . . . . . . . . . . . . . . . . . . . 83ofloxacin . . . . . . . . . . . 27, 39, 53OGEN . . . . . . . . . . . . . . . . . . . . 49olanzapine . . . . . . . . . . . . . . . . 58olanzapine ODT . . . . . . . . . . . 58olanzapine-fluoxetine . . . . . . . 59olaparib . . . . . . . . . . . . . . . . . . . 7

olmesartan medoxomil tabs . . 9olmesartan medoxomil-

hydrochlorothiazide tab 10olodaterol . . . . . . . . . . . . . .64, 65olopatadine HCl (nasal) soln . 28olopatadine HCL soln . . . . . . 51olsalazine sodium . . . . . . . . . . 36ombitas-paritapre-riton & dasab

tab pak . . . . . . . . . . . . . . . . 41omega-3-acid ethyl esters

caps . . . . . . . . . . . . . . . . . . 13omeprazole delayed-release . 35OMNICEF . . . . . . . . . . . . . . . . . 38ondansetron . . . . . . . . . . . . . . 34ondansetron HCL soln . . . . . . 34ONE TOUCH SYSTEMS . . . . 31ONE TOUCH TEST STRIPS . 31ONFI . . . . . . . . . . . . . . . . . . . . . 19ONGLYZA . . . . . . . . . . . . . . . . 31ophthalmic irrigation solution -

intraocular soln . . . . . . . . . 54OPIUM TINCTURE

(PAREGORIC) . . . . . . . . . . 34OPSUMIT . . . . . . . . . . . . . . . . . 13OPTIPRANOLOL . . . . . . . . . . 52OPTIVAR . . . . . . . . . . . . . . . . . 51ORACIT . . . . . . . . . . . . . . . . . . 67ORAP . . . . . . . . . . . . . . . . . . . . 59ORAPRED . . . . . . . . . . . . . . . . 29ORAPRED ODT . . . . . . . . . . . 29ORFADIN . . . . . . . . . . . . . . . . . 33ORKAMBI . . . . . . . . . . . . . . . . 80orphenadrine

extended-release . . . . . . . 47ORTHO COIL . . . . . . . . . . . . . 47ortho diaphragm . . . . . . . . . . . 47ORTHO EVRA . . . . . . . . . . . . . 49ORTHO FLAT . . . . . . . . . . . . . 47ORTHO FLEX . . . . . . . . . . . . . 47ORTHO MICRONOR . . . . . . . 49ORTHO TRI-CYCLEN . . . . . . . 49ORTHO TRI-CYCLEN LO . . . 49ORTHO-CEPT . . . . . . . . . . . . . 48ORTHO-CYCLEN . . . . . . . . . . 48ORTHO-NOVUM 1/35 . . . . . . 48

111



ORTHO-NOVUM 1/50 . . . . . . 49ORTHO-NOVUM 10/11 . . . . 47ORTHO-NOVUM 7/7/7 . . . . . 49ORUDIS . . . . . . . . . . . . . . .16, 46OS-CAL . . . . . . . . . . . . . . .67, 90OS-CAL CALTRATE . . . . . . . . 90oseltamivir . . . . . . . . . . . . . . . . 42OSENI . . . . . . . . . . . . . . . . . . . . 31OTEZLA . . . . . . . . . . . . . . . . . . 45OVCON 50 . . . . . . . . . . . . . . . . 49OVIDE . . . . . . . . . . . . . . . . . . . . 24OVIDREL . . . . . . . . . . . . . . . . . 50OVRAL . . . . . . . . . . . . . . . .48, 49oxaprozin . . . . . . . . . . . . . .16, 46oxazepam . . . . . . . . . . . . . . . . 54oxcarbazepine . . . . . . . . . . . . . 20OXSORALEN . . . . . . . . . . . . . . 24OXSORALEN-ULTRA . . . . . . . 24oxybutynin chloride . . . . . . . . 66oxybutynin IR . . . . . . . . . . . . . . 66oxybutynin patch. . . . . . . .66, 90oxycodone . . . . . . . . . . . . . . . . 17oxycodone HCl caps . . . . . . . 17oxycodone HCl tabs . . . . . . . . 17oxycodone/acetaminophen . 17oxycodone/aspirin . . . . . . . . . 17OXYFAST . . . . . . . . . . . . . . . . . 17OXYIR . . . . . . . . . . . . . . . . . . . . 17oxymetazoline . . . . . . . . . . . . . 28oxymorphone ER . . . . . . . . . . 17OXYTROL FOR WOMEN OTC

PATCH . . . . . . . . . . . . .66, 90

PPACERONE . . . . . . . . . . . . . . . 10PAIRE OB . . . . . . . . . . . . . . . . . 73palbociclib . . . . . . . . . . . . . . . . . 5PALGIC . . . . . . . . . . . . . . . . . . . 59paliperidone . . . . . . . . . . . . . . . 58palivizumab . . . . . . . . . . . . . . . 45PAMELOR . . . . . . . . . . . . . . . . 56PAMIDRONATE DISODIUM . 32pamidronate disodium inj . . . 32PANCREAZE . . . . . . . . . . . . . . 36pancrelipase . . . . . . . . . . . . . . 36

pancrelipase (lipase-protease-amylase) cpep . . . . . . . . . 36

pancrelipase (lipase-protease-amylase) tabs . . . . . . . . . . 36

panobinostat . . . . . . . . . . . . . . . 4PANRETIN . . . . . . . . . . . . . . . . . 6pantoprazole . . . . . . . . . . . . . . 35pantoprazole sodium pack . . 35PARAFON FORTE DSC . . . . . 46PARCOPA . . . . . . . . . . . . . . . . 19paregoric tinc . . . . . . . . . . . . . 34parenteral electrolyte conc . . 82parenteral electrolyte soln . . . 83paricalcitol caps . . . . . . . . . . . 71paricalcitol iv soln . . . . . . . . . . 71PARNATE . . . . . . . . . . . . . . . . . 56paromomycin . . . . . . . . . . . . . 45paroxetine . . . . . . . . . . . . . . . . 56PASER . . . . . . . . . . . . . . . . . . . 37pasireotide . . . . . . . . . . . . . . . . . 7PATADAY . . . . . . . . . . . . . . . . . 51PATANASE . . . . . . . . . . . . . . . . 28patiromer . . . . . . . . . . . . . . . . . 13PAXIL . . . . . . . . . . . . . . . . . . . . 56pazopanib . . . . . . . . . . . . . . . . . 5ped multivitamins w/fl & iron

liqd . . . . . . . . . . . . . . . . . . . 71ped multivitamins w/fl & iron

susp . . . . . . . . . . . . . . . . . . 71PEDIACARE LIQ MULTI-SY . . 63PEDIALYTE . . . . . . . . . . . .68, 89PEDIAPRED . . . . . . . . . . . . . . . 29PEDIATEX TDM . . . . . . . . . . . 63pediatric multiple vitamin w/

minerals & c soln . . . . . . . 71pediatric multivitamins w/fl . . 71pediatric multivitamins w/fl &

iron chew . . . . . . . . . . . . . . 71pediatric vitamins acd &

l-methylfolate w/fluoride susp . . . . . . . . . . . . . . . . . . 71

PEDIAZOLE . . . . . . . . . . . . . . . 39peg 3350/electrolytes . . . . . . 33peg 3350/sodium bicarbonate/

sodium chloride . . . . .33, 34

peg 3350/sodium bicarbonate/sodium chloride/potassium chloride . . . . . . . . . . . . . . . 34

PEG-INTRON . . . . . . . . . . . . . 41pegademase bovine soln . . . 29PEGANONE . . . . . . . . . . . . . . . 19PEGASYS . . . . . . . . . . . . . . . . . 41PEGASYS PROCLICK . . . . . . 41pegfilgrastim . . . . . . . . . . . . . . . 8peginterferon alfa-2a . . . . . . . 41peginterferon alfa-2b . . . . . 6, 41peginterferon beta-1a . . . . . . . 18pegvisomant . . . . . . . . . . . . . . 33penciclovir cream . . . . . . . . . . 25penicillamine . . . . . . . . . . . . . . 45penicillin g benzathine &

procaine inj . . . . . . . . . . . . 39penicillin g benzathine

susp im . . . . . . . . . . . . . . . 39penicillin g potassium solr inj 39PENICILLIN G PROCAINE . . 40penicillin g procaine susp . . . 40PENICILLIN G SODIUM . . . . . 40penicillin g sodium solr inj . . . 40penicillin VK . . . . . . . . . . . . . . . 40PENLAC SOLUTION 8% . . . . 23pentamidine isethionate for

nebulization . . . . . . . . . . . . 41pentazocine/naloxone . . . . . . 17pentosan polysulfate sodium 66pentoxifylline extended-release 8PEPCID . . . . . . . . . . . . . . .35, 89PEPCID AC . . . . . . . . . . . .35, 89PERCOCET . . . . . . . . . . . . . . . 17PERCODAN . . . . . . . . . . . . . . . 17PERIDEX . . . . . . . . . . . . . . . . . 28PERIKABIVEN . . . . . . . . . . . . . 80permethrin . . . . . . . . . . . . .24, 89perphenazine . . . . . . . . . .56, 59PERSANTINE . . . . . . . . . . . . . . 8PERTZYE . . . . . . . . . . . . . . . . . 36PFIZERPEN-G . . . . . . . . . . . . . 39phenazopyridine . . . . . . . . . . . 67PHENERGAN . . . . . . . . . .34, 61PHENERGAN DM . . . . . . . . . . 61phenobarbital . . . . . . . . . . . . . 20

112


Index of Covered Drugsphenyl salicylate . . . . . . . . . . . 66phenylephrine . . . 27, 28, 59-63phenylephrine-bromphen w/

codeine liqd . . . . . . . . . . . 62phenylephrine-

brompheniramine-dm liquid 62

phenylephrine-chlorphen w/codeine syrup . . . . . . . . . . 62

phenylephrine-dexchlorphenir-codeine syrup . . . . . . . . . 63

phenylephrine/brompheniramine/dextromethorphan . . . . . . 62

phenylephrine/chlorpheniramine/ dextromethorphan . . .62, 63

phenylephrine/chlorpheniramine/dihydrocodeine . . . . . . . . . 63

phenylephrine/dextromethorphan . . . . . . 63

phenylephrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 63

phenylephrine/ephed/CPM w/carbetapentane . . . . . . . . 63

phenylephrine/guaifenesin . . 63phenylephrine/pyrilamine w/

hydrocodone . . . . . . . . . . . 63PHENYLHIST LIQ DH . . . . . . 60PHENYTEK . . . . . . . . . . . . . . . 20phenytoin . . . . . . . . . . . . . . . . . 20phenytoin sodium extended . 20PHILLIPS COLON

HEALTH . . . . . . . . . . . .37, 89PHOS-FLUR . . . . . . . . . . .69, 90PHOSLO . . . . . . . . . . . . . . . . . 83PHOSPHOLINE IODINE . . . . 52phosphorus . . . . . . . . . . . . . . . 79PHRENILIN . . . . . . . . . . . . . . . 15phytonadione. . . . . . . . . . . . . . 71phytonadione soln . . . . . . . . . 71pilocarpine . . . . . . . . . . . . .28, 53PILOPINE HS GEL . . . . . . . . . 53pimecrolimus . . . . . . . . . . . . . . 26

pimozide . . . . . . . . . . . . . . . . . 59PIN-X . . . . . . . . . . . . . . . . . . . . . 37pioglitazone . . . . . . . . . . . . . . . 31pioglitazone/metformin . . . . . 31piperacillin sodium-tazobactam

sodium for inj . . . . . . . . . . 40pirfenidone capsule . . . . . . . . 83piroxicam . . . . . . . . . . . . . .16, 46PLAN B ONE STEP . . . . . . . . 47PLAQUENIL . . . . . . . . . . . .44, 45PLASMA-LYTE A . . . . . . . . . . 82PLASMA-LYTE-148 . . . . . . . . 82PLASMA-LYTE-56/D5W . . . . 82PLAVIX . . . . . . . . . . . . . . . . . . . . 8PLEGRIDY . . . . . . . . . . . . . . . . 18PLENDIL . . . . . . . . . . . . . . . . . 11plerixafor . . . . . . . . . . . . . . . . . . 8PLETAL . . . . . . . . . . . . . . . . . . . 8PLEXION . . . . . . . . . . . . . . . . . 21PLIAGLIS . . . . . . . . . . . . . . . . . 26pneumococcal 13-valent

conjugate . . . . . . . . . . . . . . 86pneumococcal vaccine

polyvalent. . . . . . . . . . . . . . 86PNEUMOVAX . . . . . . . . . . . . . 86PNEUMOVAX 23 . . . . . . . . . . 86PNV-DHA . . . . . . . . . . . . . .76, 77PNV-DHA+DOCUSATE . . . . . 76PNV-FIRST SOFTGEL . . . . . . 72PNV-OB/DHA . . . . . . . . . . . . . 72PNV-OMEGA SOFTGEL . . . . 77PNV-SELECT . . . . . . . . . . . . . . 74PNV-TOTAL . . . . . . . . . . . . . . . 73podofilox . . . . . . . . . . . . . . . . . 25POLY HIST . . . . . . . . . . . . . . . . 64POLY-TUSSIN . . . . . . . . . . 60-62POLY-TUSSIN AC . . . . . . . . . . 62POLY-TUSSIN D . . . . . . . . . . . 61POLY-VI-FLOR . . . . . . . . . .70, 71POLY-VI-FLOR/IRON . . . . . . . 71POLY-VI-SOL . . . . . . . . . . . . . . 90polyethylene glycol 3350 . . . . 34POLYMYXIN B SULFATE INJ 40polymyxin b sulfate solr . . . . . 40polymyxin B/bacitracin . .22, 53polymyxin B/trimethoprim . . . 53

polysacch fe cmplx-fe heme poly-fa-b12 tab . . . . . . . . . 71

polysaccharide iron caps . . . . 90polysaccharide iron complex 71POLYSPORIN . . . . . . . . . . . . . 53POLYTRIM . . . . . . . . . . . . . . . . 53pomalidomide . . . . . . . . . . . . . . 6POMALYST . . . . . . . . . . . . . . . . 6ponatinib . . . . . . . . . . . . . . . . . . 5pot & sod citrates w/citric ac . 71pot bicarbonate & chloride

effer tab . . . . . . . . . . . . . . . 79potassium & sodium acid

phosphates tabs . . . . . . . . 79POTASSIUM ACETATE INJ . . 79potassium acetate inj soln . . . 79potassium acid phosphate . . 79potassium bicarbonate/

potassium citrate effervescent . . . . . . . . . . . . 79

potassium chloride . . . . . .34, 79potassium chloride cpcr . . . . 79potassium chloride extended-

release . . . . . . . . . . . . . . . . 79potassium chloride in d5w

lactated ringer . . . . . . . . . . 79potassium chloride in dextrose

inj . . . . . . . . . . . . . . . . . . . . 79POTASSIUM CHLORIDE INJ 79potassium chloride

microencapsulated crystals cr tbcr . . . . . . . . . . . . . . . . . 79

potassium chloride soln . . . . . 79POTASSIUM CHLORIDE/

D5W . . . . . . . . . . . . . . . . . . 79POTASSIUM CHLORIDE/

D5W/NACL . . . . . . . . . . . . 79POTASSIUM CHLORIDE/

NACL INJ . . . . . . . . . . . . . . 79potassium citrate . . . . 66, 79, 80potassium citrate (alkalinizer)

tbcr . . . . . . . . . . . . . . . . . . . 80potassium citrate-citric acid

pack . . . . . . . . . . . . . . . . . . 80potassium iodide soln . . . . . . 80

113



POTASSIUM PHOSPHATES . 80potassium phosphates

inj soln . . . . . . . . . . . . . . . . 80POTIGA . . . . . . . . . . . . . . . . . . 19povidone-iodine . . . . . . . . . . . 45PR NATAL 400 . . . . . . . . . . . . 72PRADAXA . . . . . . . . . . . . . . . . . 7PRALUENT . . . . . . . . . . . . . . . 13pramipexole . . . . . . . . . . . . . . . 19pramipexole dihydrochloride

tb24 . . . . . . . . . . . . . . . . . . 19pramlintide . . . . . . . . . . . . . . . . 32PRANDIN . . . . . . . . . . . . . . . . . 31prasugrel HCl tabs . . . . . . . . . . 8praziquantel . . . . . . . . . . . . . . . 37prazosin . . . . . . . . . . . . . . . . . . . 9PRECOSE . . . . . . . . . . . . . . . . 31PRED FORTE . . . . . . . . . . . . . 52PRED MILD . . . . . . . . . . . . . . . 52PRED-G . . . . . . . . . . . . . . . . . . 51prednicarbate . . . . . . . . . . . . . 23prednisolone . . . . . . . 29, 51, 52prednisolone acetate . . . .51, 52prednisolone phosphate . . . . 52prednisolone sodium

phosphate . . . . . . . . . . . . . 29prednisolone sodium phosphate

soln . . . . . . . . . . . . . . . . . . . 29prednisolone sodium phosphate

tbdp . . . . . . . . . . . . . . . . . . 29prednisone . . . . . . . . . . . . . . . . 29PREFERA OB . . . . . . . . . . . . . 73PREFERAOB +DHA . . . . . . . . 73PREFOL-DHA . . . . . . . . . . . . . 76pregabalin . . . . . . . . . . . . . . . . 20PRELONE . . . . . . . . . . . . . . . . 29PREMARIN . . . . . . . . . . . . . . . 49PREMPHASE . . . . . . . . . . . . . 50PREMPRO . . . . . . . . . . . . . . . . 50PRENAISSANCE . . . . . . . 74-76PRENAISSANCE 90 DHA . . . 76PRENAISSANCE BALANCE

SOFTGEL . . . . . . . . . . . . . 75PRENAISSANCE HA . . . . . . . 75PRENAISSANCE HARMONY

DHA . . . . . . . . . . . . . . . . . . 75

PRENAISSANCE NEXT . . . . . 74PRENAISSANCE NEXT-B . . . 74PRENAISSANCE PROMISE . 76prenat vit w/iron carbonyl-fe asp

glyc-fa-omega fatty acid . . 72prenat w/o A w/fecbn-fegl-DSS-

FA & DHA . . . . . . . . . . . . . . 72prenat-FE Bis-FE prot succ-FA-

CA & omega 3 . . . . . . . . . 71prenat-FE bis-FE prot succ-FA-

CA & omega DR . . . . . . . . 72PRENATA . . . . . . . . . . . . . . . . . 77prenatal multivitamins &

minerals w/l-methylfolate-fa chew . . . . . . . . . . . . . . . . . . 72

prenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega 3 m . . . . . . . . . . . . . . . . . . . 72

prenatal mv & min w/fe carbonyl-docusate-folic acid-dha tab . . . . . . . . . . . . . . . . 72

prenatal mv & min w/fe fumarate-fa-dha misc . . . . 72

prenatal mv & min w/fe polysaccharide complex-fa-dha . . . . . . . . . . . . . . . . . . . 72

prenatal mv & min w/o vit a w/fe polysac cmplx-fa-ca-omega . . . . . . . . . . . . . . . . 73

prenatal vit w iron carbonyl-FA . . . . . . . . . . . . 74

prenatal vit w/FE bisglycinate chelate-FA . . . . . . . . . . . . . 73

prenatal vit w/fe carbonyl-fe bisglycinate-fa-fish oil cap 73

prenatal vit w/fe fum-iron polysacch complex-fa-omega 3 . . . . . . . . . . . . . . 73

prenatal vit w/fe glycine cysteinate-fa-omega 3 fatty acid . . . . . . . . . . . . . . . . . . . 73

prenatal vit w/fe poly cmplx-fe heme polypept-fa & omega 3 . . . . . . . . . . . . . . 73

prenatal vit w/FE polysac cmplx-FA . . . . . . . . . . . . . . 74

prenatal vit w/fe polysacch cmplx-fe asp-fe glyc-fa & dha . . . . . . . . . . . . . . . . . . . 73

prenatal vit w/fe polysacch cmplx-fe heme polypept-fa & dha . . . . . . . . . . . . . . . . . . . 73

prenatal vit w/fe polysacch complex-fe heme polypeptide-fa . . . . . . . . . . 73

prenatal vit w/fe polysacch complex-l methylfolate- fa-dha . . . . . . . . . . . . . . . . . 74

prenatal vit w/ferrous fumarate-fa-omega 3 fatty acids . . . 74

prenatal vit w/ferrous fumarate-folic acid tabs . . . . . . . . . . 74

prenatal vit w/ferrous fumarate-l methylfolate-folic acid . . . 74

prenatal vit w/iron carbonyl-fe aspart glyc-fa-omega 3 cap . . . . . . . . . . . . . . . . . 74

prenatal vit w/iron carbonyl-fe aspart glycinate-fa tabs . . 74

prenatal vit w/iron carbonyl-folic acid tabs . . . . . . . . . . . . . . 74

prenatal vit w/iron polysaccharide cmplx-l methylfolate-fa . . . . . . . . . . 74

prenatal vit without vit a w/fe bisglycinate-fa-omeg 3 mis . . . . . . . . . . . . . . . . . 74

prenatal vitamins w/fe asparto glycinate-folic acid tabs . . 74

prenatal w/calcium-vit b6-folic acid-ginger . . . . . . . . . . . . 74

prenatal w/calcium-vit b6-vit b12-folic acid-ginger tabs 75

prenatal w/fe asparto glycinate-l methylfolate-folic acid . . . 75

prenatal w/fe cbnyl-fe asparto glyc-fa-dss-omega 3 caps 75

prenatal w/fe fumarate-fa-dss-fish oil caps . . . . . . . . . . . . 75

114


Index of Covered Drugsprenatal w/fe polysacch cmplx-

sod feredetate-fa- omega 3 . . . . . . . . . . . . . . 75

prenatal w/o a vit w/fe fumarate-l methylfolate-folic acid . . . . . . . . . . . . . . . . . . . 75

prenatal w/o a w/ fe asparto glyc-l methylfolate-fa-dha . 75

prenatal w/o vit a w/fe carbonyl-dss-fa-dha caps . . . . . . . . 75

prenatal w/o vit a w/fe carbonyl-fe asp glyc-methfol-fa-dh . 75

prenatal w/o vit a w/fe carbonyl-fe aspart glyc-fa-fish oi . . . 76

prenatal w/o vit a w/fe carbonyl-fe aspart glyc-fa-omega 3 76

prenatal w/o vit a w/fe carbonyl-fe gluconate-dss-fa-dha . . 76

prenatal w/o vit a w/fe carbonyl-fe gluconate-fa & vit b6 . . 76

prenatal w/o vit a w/fe carbonyl-folic acid-dha caps . . . . . . 76

prenatal w/o vit a w/fe fumarate-docusate ca-folic acid-dha 76

prenatal w/o vit a w/fe fumarate-dss-fa-dha . . . . . . . . . . . . . 76

prenatal w/o vit a w/fe fumarate-fe carbonyl-dss-fa-dha ca 76

prenatal without a vit w/fe fum-iron polysacch complex -fa . . . . . . . . . . . . 77

prenatal without a vit w/fe fumarate-folic acid chew . 77

prenatal without a w/fe asp glyc-l methylfolate-fa- omega 3 . . . . . . . . . . . . . . 77

prenatal without a w/fe carbonyl-l methylfolate-fa-dha . . . . . . . . . . . . . . . . . . . 77

prenatal without a w/fe fum-fe polysacch complex-fa-dha cap . . . . . . . . . . . . . . . . . . . 77

prenatal without a w/fe fumarate-l methylfolate-fa-omega 3 . . . . . . . . . . . . . . 77

prenatal without vit a w/fe fum-fa-omega fatty acids caps 77

prenatal without vit a w/fe fumarate-fa-fish oil misc . . 77

prenatal without vit a w/fe fumarate-l methylfolate-omegas . . . . . . . . . . . . . . . 77

prenatal without vit a w/iron carbonyl-folic acid & vit b6 . . . . . . . . . . . . . . . . . . 77

prenatal without vit a w/iron polysaccharide complex-fa ca . . . . . . . . . . . . . . . . . . . . 78

PRENATE AM . . . . . . . . . . . . . 75PRENATE CHEW . . . . . . . . . . 72PRENATE DHA . . . . . . . . .75, 77PRENATE ELITE . . . . . . . . . . . 75PRENATE ENHANCE. . . . . . . 77PRENATE ESSENTIAL . . . . . . 77PRENATE MINI . . . . . . . . .75, 77PRENATE PIXIE . . . . . . . . . . . 75PRENATE RESTORE . . . . . . . 77PRENATE STAR . . . . . . . . . . . 74PRENEXA, TRIVEEN-PRX

RNF . . . . . . . . . . . . . . . . . . 76PREPARATION H . . . . . . . . . . 89PREQUE 10 . . . . . . . . . . . . . . . 72PREVACID . . . . . . . . . . . . . . . . 35PREVACID SOLUTAB . . . . . . 35PREVIDENT . . . . . . . . . . . . . . . 69PREVNAR 13 . . . . . . . . . . . . . 86PREZCOBIX . . . . . . . . . . . . . . 44PREZISTA . . . . . . . . . . . . . . . . 43PRIFTIN . . . . . . . . . . . . . . . . . . 38PRILOSEC . . . . . . . . . . . . . . . . 35primaquine. . . . . . . . . . . . . . . . 45PRIMAXIN IV . . . . . . . . . . . . . . 40primidone . . . . . . . . . . . . . . . . . 20PRIMSOL . . . . . . . . . . . . . . . . . 40PRINCIPEN . . . . . . . . . . . . . . . 39PRISTIQ . . . . . . . . . . . . . . . . . . 55PRO-CLEAR AC . . . . . . . . . . . 61PRO-RED AC . . . . . . . . . . . . . . 63PROAMATINE . . . . . . . . . . . . . 14probenecid . . . . . . . . . . . .17, 46

PROBENECID/ COLCHICINE . . . . . . . . . . 17

probiotics . . . . . . . . . . . . . .37, 89PROCALAMINE . . . . . . . . . . . 81procarbazine . . . . . . . . . . . . . . . 7PROCARDIA . . . . . . . . . . . . . . 11PROCARDIA XL . . . . . . . . . . . 11prochlorperazine . . . . . . . . . . . 34PROCRIT . . . . . . . . . . . . . . . . . . 8PROCTO-PAK . . . . . . . . . . . . . 22PROCTOFOAM HC . . . . . . . . 22PROCTOSOL HC

CREAM 2.5% . . . . . . . . . . 25PROCTOZONE

CREAM-HC 2.5% . . . . . . . 25PROGESTERONE . . . . . . . . . 50progesterone micronized

caps . . . . . . . . . . . . . . . . . . 50progesterone oil . . . . . . . . . . . 50PROGLYCEM . . . . . . . . . . . . . 29PROGRAF . . . . . . . . . . . . . . . . . 6PROLIXIN . . . . . . . . . . . . . . . . . 59PROLIXIN DECANOATE . . . . 59PROMACTA . . . . . . . . . . . . . . . 83PROMETH VC SYP

6.25-5/5 . . . . . . . . . . . . . . . 63promethazine . . . . . . 34, 61, 63promethazine &

phenylephrine . . . . . . .61, 63PROMETHAZINE HCL INJ . . 34promethazine HCL inj soln . . 34PROMETHAZINE SYP DM . . 61PROMETHAZINE VC

W/CODEINE . . . . . . . . . . . 61PROMETHAZINE

W/CODEINE . . . . . . . . . . . 61PROMETRIUM . . . . . . . . . . . . 50propafenone . . . . . . . . . . . . . . 10propafenone HCl cp12 . . . . . 10propantheline . . . . . . . . . . . . . 66propranolol . . . . . . . . . . . .11, 18propranolol HCl cp24 . . . . . . 11propranolol/HCTZ . . . . . . . . . 11propylthiouracil . . . . . . . . . . . . 33PROSCAR . . . . . . . . . . . . . . . . 66

115



PROSOL . . . . . . . . . . . . . . . . . 82PROTONIX . . . . . . . . . . . . . . . . 35PROTONIX PACKET . . . . . . . 35PROTOPIC 0.03% . . . . . . . . . 26PROTOPIC 0.1% . . . . . . . . . . . 26protriptyline HCL tabs . . . . . . 56PROVENTIL . . . . . . . . . . . . . . . 65PROVERA . . . . . . . . . . . . .47, 50PROVIDA DHA . . . . . . . . . . . . 77PROVIDA OB . . . . . . . . . . . . . . 77PROZAC . . . . . . . . . . . . . . . . . 56PRUET DHA PAK SETONET

PAK . . . . . . . . . . . . . . . . . . . 71PRUET DHAEC PAK . . . . . . . 72PSE/GG . . . . . . . . . . . . . . . . . . 62pseudoeph-chlorphen

w/hydrocodone soln . . . . 63pseudoephed-chlorphen-

dm liq . . . . . . . . . . . . . . . . 63pseudoephed-triprolidine-dm

susp . . . . . . . . . . . . . . . . . . 63pseudoephedrine tan/

dexchlorphen tan/ DM tan . . . . . . . . . . . . . . . . 64

pseudoephedrine w/cod-gg . 64pseudoephedrine w/

hydrocodone soln . . . . . . 64pseudoephedrine-bromphen-

codeine liq . . . . . . . . . . . . 63pseudoephedrine-

dexbromphen-codeine liqd . . . . . . . . . . . . . . . . . . . 64

pseudoephedrine-guaifenesin cap . . . . . . . . . . . . . . . . . . . 64

pseudoephedrine/acetaminophen/dextromethorphan . . . . . . 63

pseudoephedrine/chlorpheniramine/dextromethorphan . . . . . . 63

pseudoephedrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 64

pseudoephedrine/ iburprofen . . . . . . . . . . . . . 64

psyllium . . . . . . . . . . . . . . . . . . 89

PULMICORT RESPULES . . . 65PULMOZYME . . . . . . . . . . . . . 80PUREFE OB . . . . . . . . . . . . . . 77PURINETHOL . . . . . . . . . . . . . . 4pyrantel pamoate . . . . . . . . . . 37pyrazinamide . . . . . . . . . . . . . . 38pyrethrins/piperonyl butoxide

shampoo . . . . . . . . . . .24, 89PYRIDIUM . . . . . . . . . . . . . . . . 67pyridostigmine . . . . . . . . . . . . . 18pyridostigmine

extended-release . . . . . . . 18PYRIDOXINE HCL INJ . . . . . . 78pyridoxine HCL inj soln . . . . . 78pyrilamine tan/phenyleph

tan . . . . . . . . . . . . . . . . . . . . 64pyrilamine-phenylephrine

tab . . . . . . . . . . . . . . . . . . . . 64pyrimethamine . . . . . . . . . . . . 45

QQUARTETTE . . . . . . . . . . . . . . 48QUESTRAN . . . . . . . . . . . . . . . 12QUESTRAN-LIGHT . . . . . . . . . 12quetiapine . . . . . . . . . . . . . . . . 58quetiapine fumarate tb24 . . . 58QUILLIVANT XR . . . . . . . . . . . 55quinapril . . . . . . . . . . . . . . . . . . . 9quinapril/hydrochlorothiazide . 9QUINIDINE GLUCONATE

EXT-REL . . . . . . . . . . . . . . 10quinidine gluconate

extended-release . . . . . . . 10quinidine sulfate . . . . . . . . . . . 10QUINIDINE SULFATE

EXT-REL . . . . . . . . . . . . . . 10quinidine sulfate extended-

release . . . . . . . . . . . . . . . . 10QVAR REDIHALER . . . . . . . . . 64

RR-TANNAMINE . . . . . . . . . . . . 60raloxifene . . . . . . . . . . . . . . . . . 32raltegravir . . . . . . . . . . . . . . . . . 42raltegravir susp . . . . . . . . . . . . 42ramipril . . . . . . . . . . . . . . . . . . . . 9

RANEXA . . . . . . . . . . . . . . . . . 14ranitidine . . . . . . . . . . . . . . . . . 35RANITIDINE HCL . . . . . . . . . . 35ranitidine HCL soln . . . . . . . . . 35ranitidine HCL tabs . . . . . . . . . 35ranitidine syrup . . . . . . . . . . . . 35ranolazine . . . . . . . . . . . . . . . . 14RAPAMUNE. . . . . . . . . . . . . . . . 6RAVICTI . . . . . . . . . . . . . . . . . . 84RAZADYNE . . . . . . . . . . . . . . . 15REBETOL/COPEGUS . . . . . . 42RECLAST INJ . . . . . . . . . . . . . 32RECOMBIVAX HB . . . . . . . . . 85rectal crm, suppositories . . . . 89RECTIV . . . . . . . . . . . . . . . . . . . 26REESE’S PINWORM

MEDICINE . . . . . . . . . . . . . 37REGLAN . . . . . . . . . . . . . . . . . 34regorafenib . . . . . . . . . . . . . . . . 5REGRANEX . . . . . . . . . . . . . . . 25RELAFEN . . . . . . . . . . . . . . . . . 16RELENZA. . . . . . . . . . . . . . . . . 42RELION 70/30 . . . . . . . . . . . . 30RELION N . . . . . . . . . . . . . . . . 30RELION R . . . . . . . . . . . . . . . . 30RELNATE DHA . . . . . . . . . . . . 74REMEDY ANTIMICROBIAL

CLEANSER . . . . . . . . . . . . 25REMERON . . . . . . . . . . . . . . . . 57RENACIDIN . . . . . . . . . . . . . . . 83RENAGEL . . . . . . . . . . . . . . . . 67RENVELA . . . . . . . . . . . . . . . . 83repaglinide . . . . . . . . . . . . . . . . 31REQUIP . . . . . . . . . . . . . . . . . . 19RESCRIPTOR . . . . . . . . . . . . . 42RESPAIRE-30 . . . . . . . . . . . . . 64RESTASIS . . . . . . . . . . . . . . . . 53RESTORIL . . . . . . . . . . . . . . . . 57RETIN-A . . . . . . . . . . . . . . . . . . 21RETROVIR . . . . . . . . . . . . . . . . 43RETROVIR IV INFUSION . . . . 43REVATIO . . . . . . . . . . . . . . . . . 14REVATIO SUSPENSION . . . . 14REVIA . . . . . . . . . . . . . . . . .54, 57REVLIMID . . . . . . . . . . . . . . . . . 6REYATAZ . . . . . . . . . . . . . . . . . 43

116


Index of Covered DrugsREYATAZ POWDER PACKET 43REZIRA . . . . . . . . . . . . . . . . . . 64RIBASPHERE RIBAPAK . . . . 42RIBATAB . . . . . . . . . . . . . . . . . 42ribavirin . . . . . . . . . . . . . . . . . . . 42RID SHAMPOO . . . . . . . . .24, 89RIDAURA . . . . . . . . . . . . . . . . . 45rifabutin . . . . . . . . . . . . . . . . . . 38RIFADIN . . . . . . . . . . . . . . . . . . 38rifampin . . . . . . . . . . . . . . . . . . 38rifapentine . . . . . . . . . . . . . . . . 38rilpivirine . . . . . . . . . . . . . . . 42-44RILUTEK . . . . . . . . . . . . . . . . . 15riluzole . . . . . . . . . . . . . . . . . . . 15rimantadine . . . . . . . . . . . . . . . 42ringer’s irrigation soln . . . . . . . 83ringer’s solution . . . . . . . . .82, 83RINGERS INJECTION . . . . . . 83RINGERS IRRIGATION . . . . . 83riociguat . . . . . . . . . . . . . . . . . . 13RISA-BID . . . . . . . . . . . . . .37, 89RISAQUAD . . . . . . . . . . . . .37, 89RISPERDAL . . . . . . . . . . . . . . . 58RISPERDAL CONSTA . . . . . . 58RISPERDAL M-TAB . . . . . . . . 58RISPERDAL SOLUTION . . . . 58risperidone . . . . . . . . . . . . . . . . 58risperidone ODT . . . . . . . . . . . 58risperidone oral soln . . . . . . . . 58RITALIN . . . . . . . . . . . . . . . . . . 55RITALIN LA . . . . . . . . . . . . . . . 55ritonavir . . . . . . . . . . . . . . . .43, 44rivaroxaban . . . . . . . . . . . . . . . . 7rivastigmine . . . . . . . . . . . . . . . 15rizatriptan . . . . . . . . . . . . . . . . . 18RMS . . . . . . . . . . . . . . . . . . . . . 17ROBAXIN . . . . . . . . . . . . . . . . . 47ROBINUL . . . . . . . . . . . . . . . . . 35ROBITUSSIN . . . . . . . . 60-63, 88ROBITUSSIN CF . . . . . . . .62, 88ROBITUSSIN DM . . . . . . .61, 88ROBITUSSIN LIQ CGH/

ALRG . . . . . . . . . . . . . . . . . 62ROBITUSSIN LIQ CGH/

CLD . . . . . . . . . . . . . . .60, 63

ROBITUSSIN LIQ CGH/ CONG . . . . . . . . . . . . . . . . 61

ROBITUSSIN LIQ HD/CHST . 63ROBITUSSIN LIQ PED

NGHT . . . . . . . . . . . . . . . . . 63ROBITUSSIN PE . . . . . . . .62, 88ROBITUSSIN PED LIQ CGH/

COLD . . . . . . . . . . . . . . . . . 60ROBITUSSIN PED SYP . . . . . 61ROBITUSSIN SYP CHST

CNG . . . . . . . . . . . . . . . . . . 61ROBITUSSIN SYP MAX-ST . . 61ROCALTROL . . . . . . . . . . . . . . 67ROCALTROL SOLUTION . . . 67ROCEPHIN . . . . . . . . . . . . . . . 38roflumilast . . . . . . . . . . . . . . . . 66rolapitant . . . . . . . . . . . . . . . . . 34RONDEC DM . . . . . . . . . .62, 63RONDEC DM DROPS . . . . . . 62RONDEC DROPS . . . . . . . . . . 60RONDEC SYRUP . . . . . . . . . . 60ropinirole . . . . . . . . . . . . . . . . . 19ROWASA . . . . . . . . . . . . . . . . . 36ROXICODONE . . . . . . . . . . . . 17RUBRACA . . . . . . . . . . . . . . . . . 7rucaparib . . . . . . . . . . . . . . . . . . 7RUCONEST . . . . . . . . . . . . . . . 83rufinamide . . . . . . . . . . . . . . . . 20ruxolitinib . . . . . . . . . . . . . . . . . . 5RYDAPT . . . . . . . . . . . . . . . . . . . 5RYNA-12 S . . . . . . . . . . . . . . . 64RYNATAN PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 60RYNATUSS PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 63RYTHMOL . . . . . . . . . . . . . . . . 10RYTHMOL SR . . . . . . . . . . . . . 10

SSABRIL SOLUTION . . . . . . . . 20sacubitril/valsartan . . . . . . . . . 10SAIZEN . . . . . . . . . . . . . . . . . . . 32SAL-TROPINE . . . . . . . . . . . . . 37SALAGEN . . . . . . . . . . . . . . . . 28salicylic acid . . . . 21, 24, 25, 90

salicylic acid 17%/ collodion . . . . . . . . . . .25, 90

saline injection bacteriostatic 83saline injection w/benzyl

alcohol . . . . . . . . . . . . . . . . 84saline nasal spray 0.65% . . . . 28salsalate . . . . . . . . . . . . . . . . . . 46SANCTURA . . . . . . . . . . . . . . . 67SANDIMMUNE . . . . . . . . . . . . . 6SANDIMMUNE INJ . . . . . . . . . . 6SANDIMMUNE ORAL

SOLUTION . . . . . . . . . . . . . 6SANDOSTATIN . . . . . . . . . . . . . 7SANTYL . . . . . . . . . . . . . . . . . . 25sapropterin . . . . . . . . . . . . . . . . 33sapropterin powder . . . . . . . . 33saquinavir mesylate . . . . . . . . 44SARAFEM . . . . . . . . . . . . . . . . 56sargramostim. . . . . . . . . . . . . . . 8sarilumab . . . . . . . . . . . . . . . . . 45SAVAYSA . . . . . . . . . . . . . . . . . . 7saxagliptin . . . . . . . . . . . . . . . . 31SCALPICIN . . . . . . . . . . . . . . . 24scopolamine . . . . . . . . . . .21, 52scopolamine pt72 . . . . . . . . . . 21SE-TAN DHA . . . . . . . . . . . . . . 73SEASONALE . . . . . . . . . . . . . . 47SEASONIQUE . . . . . . . . . . . . . 48SECTRAL . . . . . . . . . . . . . . . . . 10secukinumab . . . . . . . . . . . . . . 45SEDAPAP . . . . . . . . . . . . . . . . . 15SEGLUROMET . . . . . . . . . . . . 31SELECT-OB . . . . . . . . . . . .72, 74SELECT-OB+DHA . . . . . . . . . 72selegiline . . . . . . . . . . . . . . . . . 19selenious acid inj soln . . . . . . 78SELENIUM INJ . . . . . . . . . . . . 78selenium sulfide . . . . . . . . . . . 26selenium sulfide-pyrithione zinc

in urea shampoo . . . . . . . 26SELSUN . . . . . . . . . . . . . . . . . . 26SELZENTRY . . . . . . . . . . . . . . 44sennosides . . . . . . . . . . . . . . . 34SENOKOT . . . . . . . . . . . . . . . . 34SENSIPAR . . . . . . . . . . . . . . . . 83SENTRA AM . . . . . . . . . . . . . . 71

117



SERAX . . . . . . . . . . . . . . . . . . . 54SEROMYCIN . . . . . . . . . . . . . . 37SEROQUEL . . . . . . . . . . . . . . . 58SEROQUEL XR . . . . . . . . . . . . 58SEROSTIM . . . . . . . . . . . . . . . . 32sertraline . . . . . . . . . . . . . . . . . 56sevelamer . . . . . . . . . . . . . .67, 83sevelamer HCl tabs . . . . . . . . 67SIGNIFOR . . . . . . . . . . . . . . . . . 7sildenafil . . . . . . . . . . . . . . . . . . 14SILVADENE . . . . . . . . . . . . . . . 22SILVER NITRATE . . . . . . . . . . 22silver nitrate soln . . . . . . . . . . . 22silver sulfadiazine . . . . . . . . . . 22SIMBRINZA . . . . . . . . . . . . . . . 52simethicone . . . . . . . . . . . .34, 89SIMILAC PRENATAL EARLY

SHIELD . . . . . . . . . . . . . . . 72simvastatin . . . . . . . . . . . . . . . . 13SINEMET . . . . . . . . . . . . . . . . . 19SINEMET CR . . . . . . . . . . . . . . 19SINEQUAN . . . . . . . . . . . . . . . 56SINGULAIR . . . . . . . . . . . . . . . 65sirolimus . . . . . . . . . . . . . . . . . . . 6SIRTURO . . . . . . . . . . . . . . . . . 44sitagliptin phosphate . . . . . . . 32sitagliptin-metformin . . . . .31, 32sitagliptin-metformin HCL sr

24hr . . . . . . . . . . . . . . . . . . 32SKLICE . . . . . . . . . . . . . . . . . . . 24SLOW FE . . . . . . . . . . . . . . . . . 69SM SLOW RELEASE IRON . . 69SODIUM ACETATE INJ . . . . . 83sodium acetate inj soln . . . . . 83SODIUM BICARBONATE INJ 83sodium bicarbonate inj soln . 83sodium chloride (diagnostic aid)

soln . . . . . . . . . . . . . . . . . . . 14sodium chloride (gu irrigant)

soln . . . . . . . . . . . . . . . . . . . 83SODIUM CHLORIDE 0.9%

INJ . . . . . . . . . . . . . . . . . . . 83SODIUM CHLORIDE

BACTERIOSTATIC/BENZYL ALCOHOL . . . . . . . . . . . . . 84

sodium chloride for nebulizer 80

sodium chloride hypertonic . 54SODIUM CHLORIDE INJ .40, 83sodium chloride soln . . . . . 7, 83SODIUM CHLORIDE

THERMOJECT SYSTEM . 14sodium citrate & citric acid

soln . . . . . . . . . . . . . . . . . . . 67sodium citrate/citric acid . . . . 67sodium ferric gluconate complex

in sucrose soln . . . . . . . . . 78sodium iodide soln . . . . . . . . . 78SODIUM LACTATE INJ . . . . . 83sodium lactate inj soln . . . . . . 83sodium phenylbutyrate . . . . . 84SODIUM PHOSPHATE INJ . . 83sodium phosphate inj soln . . 83sodium phosphate

monobasic . . . . . . . . . . . . . 66sodium polystyrene

sulfonate . . . . . . . . . . .13, 14sodium polystyrene sulfonate

powd . . . . . . . . . . . . . . . . . 14sofosbuvir/velpatasvir. . . . . . . 42solifenacin succinate tabs . . . 67SOLIQUA . . . . . . . . . . . . . . . . . 31SOLTAMOX . . . . . . . . . . . . . . . . 5SOLU-CORTEF INJ . . . . . . . . 29SOLU-MEDROL . . . . . . . . . . . 29somatropin . . . . . . . . . . . . . . . . 32SOMAVERT . . . . . . . . . . . . . . . 33SONATA . . . . . . . . . . . . . . . . . . 57sonidegib . . . . . . . . . . . . . . . . . . 7sorafenib . . . . . . . . . . . . . . . . . . 5SORBITOL . . . . . . . . . . . . . . . . 84sorbitol irrigation soln . . . . . . . 84SORBITOL-MANNITOL . . . . . 84sorbitol-mannitol irrig soln . . . 84SORIATANE . . . . . . . . . . . . . . . 24sotalol . . . . . . . . . . . . . . . . .10, 11sotalol HCl AF . . . . . . . . . . . . . 11spacers . . . . . . . . . . . . . . . . . . . 84spinosad . . . . . . . . . . . . . . . . . 24SPIRIVA . . . . . . . . . . . . . . . . . . 65spironolactone. . . . . . . . . . . . . 12spironolactone/

hydrochlorothiazide . . . . . 12

SPORANOX . . . . . . . . . . . . . . . 41SPRYCEL . . . . . . . . . . . . . . . . . . 4SSKI . . . . . . . . . . . . . . . . . . . . . 80STADOL . . . . . . . . . . . . . . . . . . 16STALEVO . . . . . . . . . . . . . . . . . 19STARLIX . . . . . . . . . . . . . . . . . . 31STATUSS DM SYP . . . . . . . . . 63stavudine . . . . . . . . . . . . . . . . . 43STEGLATRO . . . . . . . . . . . . . . 31STELARA . . . . . . . . . . . . . . . . . . 6STELAZINE . . . . . . . . . . . . . . . 59STERILE DILUENT FOR

FLOLAN . . . . . . . . . . . . . . . 14STERILE WATER FOR

INJECTION . . . . . . . . . . . . 84STERILE WATER

IRRIGATION . . . . . . . . . . . 84STIMATE . . . . . . . . . . . . . . . . . 33STIOLTO RESPIMAT . . . . . . . 65STIVARGA . . . . . . . . . . . . . . . . . 5stool softeners . . . . . . . . . . . . . 89STRATTERA . . . . . . . . . . . . . . 55STRENSIQ . . . . . . . . . . . . . . . . 33STRIBILD . . . . . . . . . . . . . . . . . 44STRIVERDI RESPIMAT . . . . . 64STROMECTOL . . . . . . . . . . . . 37STUART PRENATAL . . . . . . . 90SUBOXONE . . . . . . . . . . . . . . . 57SUBUTEX . . . . . . . . . . . . . . . . 57succimer . . . . . . . . . . . . . . . . . 80sucralfate . . . . . . . . . . . . . . . . . 35sugar+orthophosphoric acid 89sulcralfate . . . . . . . . . . . . . . . . . 35SULFACET-R . . . . . . . . . . . . . . 21sulfacetamide . . . 21, 24, 51, 53sulfacetamide sodium w/sulfur

foam . . . . . . . . . . . . . . . . . . 24sulfacetamide/pred phos . . . 51sulfacetamide/sulfur . . . . . . . . 21sulfadiazine . . . . . . . . . . . .22, 40sulfamethoxazole/trimethoprim,

DS . . . . . . . . . . . . . . . . . . . . 40SULFAMYLON . . . . . . . . . . . . 22sulfasalazine . . . . . . . . . . .36, 45sulfasalazine

delayed-release . . . . . .36, 45

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Index of Covered Drugssulindac . . . . . . . . . . . . . . .16, 46sumatriptan . . . . . . . . . . . . . . . 18SUMYCIN . . . . . . . . . . . . . . . . . 40sunitinib . . . . . . . . . . . . . . . . . . . 5SUPRAX . . . . . . . . . . . . . . . . . . 38SUPRAX SUSPENSION . . . . . 38SUSTIVA . . . . . . . . . . . . . . . . . . 42SUTENT . . . . . . . . . . . . . . . . . . . 5SUTTAR-SF . . . . . . . . . . . . . . . 64SYLATRON . . . . . . . . . . . . . . . . 6SYMBICORT . . . . . . . . . . . . . . 65SYMBYAX . . . . . . . . . . . . . . . . 59SYMLIN . . . . . . . . . . . . . . . . . . 32SYMMETREL . . . . . . . . . .19, 42SYNAGIS . . . . . . . . . . . . . . . . . 45SYNALAR . . . . . . . . . . . . .22, 23SYNTHROID . . . . . . . . . . . . . . 32

TT-STAT . . . . . . . . . . . . . . . . . . . 21TABLOID . . . . . . . . . . . . . . . . . . 4tacrolimus . . . . . . . . . . . . . . 6, 26TAFINLAR . . . . . . . . . . . . . . . . . 4TAGAMET . . . . . . . . . . . . . . . . 34taliglucerase alfa solr . . . . . . . 33TALWIN NX . . . . . . . . . . . . . . . 17TAMBOCOR . . . . . . . . . . . . . . 10TAMIFLU . . . . . . . . . . . . . . . . . 42tamoxifen . . . . . . . . . . . . . . . . . . 5tamoxifen citrate soln . . . . . . . . 5tamsulosin . . . . . . . . . . . . . . . . 66TANAFED DMX

SUSPENSION . . . . . . . . . . 64TANDEM PLUS . . . . . . . . . . . . 68TANZEUM . . . . . . . . . . . . . . . . 32TAPAZOLE . . . . . . . . . . . . . . . . 33TARCEVA . . . . . . . . . . . . . . . . . . 4TARGRETIN . . . . . . . . . . . . . . . . 6TARON FORTE . . . . . . . . . . . . 68TARON-BC . . . . . . . . . . . . . . . . 77TARON-C DHA . . . . . . . . . . . . 73TARON-PREX . . . . . . . . . . . . . 76TASIGNA . . . . . . . . . . . . . . . . . . 5TASMAR . . . . . . . . . . . . . . . . . . 19TAZICEF . . . . . . . . . . . . . . . . . . 38TBO-filgrastim . . . . . . . . . . . . . . 8

TECFIDERA . . . . . . . . . . . . . . . 18teduglutide . . . . . . . . . . . . . . . . 37TEGRETOL . . . . . . . . . . . . . . . 19TEGRETOL-XR . . . . . . . . . . . . 19telbivudine tabs . . . . . . . . . . . . 42telmisartan . . . . . . . . . . . . . . . . . 9telmisartan-

hydrochlorothiazide . . . . . . 9temazepam . . . . . . . . . . . . . . . 57TEMODAR . . . . . . . . . . . . . . . . . 4TEMOVATE . . . . . . . . . . . . . . . 23temozolomide . . . . . . . . . . . . . . 4TENEX . . . . . . . . . . . . . . . . . . . . 9TENIVAC . . . . . . . . . . . . . . . . . 86tenofovir . . . . . . . . . . . . . . .43, 44TENORETIC . . . . . . . . . . . . . . 10TENORMIN . . . . . . . . . . . . . . . 10TERAZOL 3/7 . . . . . . . . . . . . . 50terazosin . . . . . . . . . . . . . . . . 9, 66terbinafine . . . . . . . . . . . . .24, 41terbutaline . . . . . . . . . . . . .65, 66TERBUTALINE SULFATE

INJ . . . . . . . . . . . . . . . . . . . 66terbutaline sulfate inj soln . . . 66terconazole . . . . . . . . . . . . . . . 50teriflunomide . . . . . . . . . . . . . . 18tesamorelin . . . . . . . . . . . . . . . 32TESSALON . . . . . . . . . . . . . . . 59TESTOSTERONE 1% TOPICAL

GEL . . . . . . . . . . . . . . . . . . 29testosterone cypionate . . . . . . 29testosterone enanthate . . . . . . 29testosterone gel . . . . . . . . . . . . 29testosterone gel topical tube,

packet, and pump bottle . 29tet tox-diph-acell pertuss ad . 86TET/DIP TOX INJ . . . . . . . . . . 86tetanus immune globulin

(human) . . . . . . . . . . . . . . . 86tetanus-diphtheria toxoids (td) 86tetrabenazine . . . . . . . . . . . . . . 21tetracycline . . . . . . . . . . . . . . . . 40tetrahydrozoline/zinc sulfate . 51thalidomide . . . . . . . . . . . . . . . . 6THALOMID . . . . . . . . . . . . . . . . 6THEO-24 . . . . . . . . . . . . . . . . . 66

THEOCHRON . . . . . . . . . . . . . 66theophylline . . . . . . . . . . . .65, 66theophylline

extended-release . . . . . . . 66theophylline soln . . . . . . . . . . . 66THERANATAL COMPLETE . . 72THERANATAL PLUS . . . . . . . 72THIAMINE HCL INJ . . . . . . . . 78thiamine HCL inj soln . . . . . . . 78thioguanine . . . . . . . . . . . . . . . . 4THIOLA . . . . . . . . . . . . . . . . . . 67thioridazine . . . . . . . . . . . . . . . 59thiothixene . . . . . . . . . . . . . . . . 59THORAZINE . . . . . . . . . . . . . . 59thyroid . . . . . . . . . . . . . . 2, 32, 33THYROLAR . . . . . . . . . . . . . . . 33tiagabine . . . . . . . . . . . . . . . . . 20TIAZAC . . . . . . . . . . . . . . . . . . . 11ticagrelor . . . . . . . . . . . . . . . . . . 8TIGAN . . . . . . . . . . . . . . . . . . . . 34TIKOSYN . . . . . . . . . . . . . . . . . 10timolol . . . . . . . . . . . . . . . . . . . . 52timolol maleate . . . . . . . . . . . . 52TIMOPTIC . . . . . . . . . . . . . . . . 52TIMOPTIC XE . . . . . . . . . . . . . 52TINACTIN . . . . . . . . . . . . . .24, 87TINDAMAX . . . . . . . . . . . . . . . 41tinidazole . . . . . . . . . . . . . . . . . 41tioconazole vaginal oint . . . . . 50TIOCONAZOLE-1 . . . . . . . . . . 50tiopronin . . . . . . . . . . . . . . . . . . 67tiotropium . . . . . . . . . . . . . . . . . 65tiotropium/olodaterol . . . . . . . 65tipranavir . . . . . . . . . . . . . . . . . 44TIVICAY . . . . . . . . . . . . . . . . . . 42tizanidine . . . . . . . . . . . . . . . . . 47TL FOLATE . . . . . . . . . . . . . . . 74TL-SELECT . . . . . . . . . . . . . . . 76TOBI . . . . . . . . . . . . . . . . . . . . . 80TOBRADEX . . . . . . . . . . . . . . . 51tobramycin . . . . . . 40, 51, 53, 80tobramycin neb soln . . . . . . . . 80tobramycin sulfate in

saline soln . . . . . . . . . . . . . 40TOBRAMYCIN SULFATE INJ 40tobramycin sulfate soln . . . . . 40

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TOBRAMYCIN SULFATE/SODIUM CHLORIDE INJ . 40

tobramycin/dexamethasone . 51TOBREX . . . . . . . . . . . . . . . . . . 53TOFRANIL . . . . . . . . . . . . . . . . 56TOFRANIL-PM . . . . . . . . . . . . . 56tolazamide . . . . . . . . . . . . . . . . 32tolbutamide . . . . . . . . . . . . . . . 32tolcapone . . . . . . . . . . . . . . . . . 19TOLINASE . . . . . . . . . . . . . . . . 32tolnaftate . . . . . . . . . . . . . .24, 87tolterodine . . . . . . . . . . . . . . . . 67TOPAMAX . . . . . . . . . . . . . . . . 20TOPAMAX SPRINKLE . . . . . . 20topical antibacterials . . . . . . . . 88topiramate . . . . . . . . . . . . . . . . 20topiramate sprinkle caps . . . . 20topotecan . . . . . . . . . . . . . . . . . . 7TOPROL XL . . . . . . . . . . . . . . . 10TORADOL . . . . . . . . . . . . . . . . 16toremifene . . . . . . . . . . . . . . . . . 5torsemide . . . . . . . . . . . . . . . . . 12torsemide soln . . . . . . . . . . . . . 12TOUJEO SOLOSTAR . . . . . . . 30TOVIAZ . . . . . . . . . . . . . . . . . . . 66TRACE ELEMENTS 4/

PEDIATRIC . . . . . . . . . . . . 78trace min (cr-cu-mn-se-zn) inj 78TRACLEER . . . . . . . . . . . . . . . 13TRADJENTA . . . . . . . . . . . . . . 31tramadol . . . . . . . . . . . . . . . . . . 15trametinib . . . . . . . . . . . . . . . . . . 5TRANDATE . . . . . . . . . . . . . . . 10trandolapril . . . . . . . . . . . . . . . . . 9tranexamic acid . . . . . . . . . . . . 51tranexamic acid soln . . . . . . . 51TRANSDERM-SCOP . . . . . . . 21TRANXENE . . . . . . . . . . . . . . . 54tranylcypromine . . . . . . . . . . . . 56TRAVATAN Z . . . . . . . . . . . . . . 53travoprost soln . . . . . . . . . . . . . 53trazodone . . . . . . . . . . . . . .17, 57TRAZODONE HCL . . . . . . . . . 17trazodone HCl tabs . . . . . . . . . 17TRECATOR . . . . . . . . . . . . . . . 38TRENTAL . . . . . . . . . . . . . . . . . . 8

tretinoin . . . . . . . . . . . . . . . . 7, 21TRI-FED X. . . . . . . . . . . . . . . . . 64TRI-NORINYL . . . . . . . . . . . . . 49TRI-VI-FLOR . . . . . . . . . . . .71, 78TRI-VI-SOL . . . . . . . . . . . . .78, 90triamcinolone . . . . . . . 23, 28, 29triamcinolone acetonide .23, 29triamcinolone acetonide susp 29triamcinolone nasal spray . . . 28TRIAMINIC COUGH &

CONGESTION CHILDRENS . . . . . . . . . . . 61

triamterene/ hydrochlorothiazide . . . . . 12

TRIAVIL . . . . . . . . . . . . . . . . . . 56triazolam . . . . . . . . . . . . . . . . . . 57TRICARE PRENATAL

COMPLEAT . . . . . . . . . . . . 77TRICARE PRENATAL

DHA ONE . . . . . . . . . . . . . 75TRICITRATES . . . . . . . . . . . . . 71trifluoperazine . . . . . . . . . . . . . 59trifluridine . . . . . . . . . . . . . . . 4, 54trifluridine/tipiracil . . . . . . . . . . . 4trihexyphenidyl . . . . . . . . . . . . 19TRILAFON . . . . . . . . . . . . . . . . 59TRILEPTAL . . . . . . . . . . . . . . . 20TRILYTE . . . . . . . . . . . . . . . . . . 33trimethobenzamide . . . . . . . . 34trimethoprim . . . . . . . 40, 45, 53trimethoprim HCL soln . . . . . . 40TRINTELLIX . . . . . . . . . . . . . . . 57TRIOTANN . . . . . . . . . . . . .27, 60TRIOTANN PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 60tripolidine/pseudoephedrine 64TRIPROL/PSE SYP . . . . . . . . 64TRISTART DHA . . . . . . . . . . . . 77TRIUMEQ . . . . . . . . . . . . . . . . . 44TRIVORA . . . . . . . . . . . . . . . . . 49TRIZIVIR . . . . . . . . . . . . . . . . . . 43TROJAN . . . . . . . . . . . . . . . . . . 88TROPHAMINE . . . . . . . . . . . . . 82trospium . . . . . . . . . . . . . . . . . . 67TRULICITY . . . . . . . . . . . . . . . . 32TRUSOPT . . . . . . . . . . . . . . . . 52

TRUST NATALCARE PAK DHA . . . . . . . . . . . . . . 71

TRUSTEX . . . . . . . . . . . . . . . . . 88TRUVADA . . . . . . . . . . . . . . . . 43TUMS . . . . . . . . . . . . . . . . .89, 90TUSSI-12 S . . . . . . . . . . . . . . . 60TUSSICAPS . . . . . . . . . . . . . . . 62TUSSIN DM . . . . . . . . . . . . . . . 61TUSSIONEX PENNKINETIC

EXTENDED-RELEASE . . 62TYBOST . . . . . . . . . . . . . . . . . . 44TYKERB . . . . . . . . . . . . . . . . . . . 5TYLENOL . . . . . . . 15, 16, 45, 90TYLENOL W/CODEINE . . . . . 16TYMLOS . . . . . . . . . . . . . . . . . 32typhoid vaccine . . . . . . . . . . . . 86TYSABRI . . . . . . . . . . . . . . . . . 37TYZEKA . . . . . . . . . . . . . . . . . . 42

UUDAMIN SP . . . . . . . . . . . . . . . 70ULESFIA . . . . . . . . . . . . . . . . . . 24ulipristal acetate . . . . . . . . . . . 47ULORIC . . . . . . . . . . . . . . . . . . 46ULTIMATECARE ONE . . .74, 75ULTIMATECARE ONE NF . . . 75ULTRA . . . . . . . . . . . . . . . .31, 74ULTRA 2, ULTRAMINI . . . . . . 31ULTRAM . . . . . . . . . . . . . . . . . . 15ULTRAVATE . . . . . . . . . . . . . . . 23ULTRESA . . . . . . . . . . . . . . . . . 36umeclidinium inhalation . . . . . 65UNASYN . . . . . . . . . . . . . . . . . 39UNI-HIST DROPS . . . . . . . . . . 59UNIPHYL . . . . . . . . . . . . . . . . . 66UNISOM . . . . . . . . . . . . . . .57, 89UREA 10% CREAM, UREA

20% CREAM, UREA 10% LOTION . . . . . . . . . . . . . . . 26

urea 10%, urea 20% . . . . . . . . 26urea 40% . . . . . . . . . . . . . . . . . 26UREA 40% LOTION . . . . . . . . 26urea crea . . . . . . . . . . . . . . . . . 26URECHOLINE . . . . . . . . . . . . . 66UREX . . . . . . . . . . . . . . . . . . . . 66uridine . . . . . . . . . . . . . . . . . . . 33

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Index of Covered DrugsUROCIT-K . . . . . . . . . . . . .66, 80UROCIT-K 15 . . . . . . . . . . . . . . 80UROXATRAL . . . . . . . . . . . . . . 66URSO . . . . . . . . . . . . . . . . . . . . 37URSO FORTE . . . . . . . . . . . . . 37ursodiol . . . . . . . . . . . . . . . . . . 37ustekinumab sosy . . . . . . . . . . . 6UTIRA C . . . . . . . . . . . . . . . . . . 66

VVAGIFEM . . . . . . . . . . . . . . . . . 49vaginal products . . . . . . . . . . . 87valacyclovir . . . . . . . . . . . . . . . . 42valbenazine . . . . . . . . . . . . . . . 21VALCYTE . . . . . . . . . . . . . . . . . 41valganciclovir . . . . . . . . . . . . . . 41VALIUM . . . . . . . . . . . . . . .47, 54valproic acid . . . . . . . . . . . . . . 20valsartan . . . . . . . . . . . . . . . . 9, 10valsartan-hydrochlorothiazide 9VALTREX . . . . . . . . . . . . . . . . . 42VANCOCIN HCL . . . . . . . . . . . 40vancomycin HCl . . . . . . . . . . . 40vancomycin HCl solr inj . . . . . 40vandetanib . . . . . . . . . . . . . . . . . 5VAQTA . . . . . . . . . . . . . . . . . . . 85varenicline . . . . . . . . . . . . . . . . 58varicella virus vac live for

subcutaneous . . . . . . . . . . 86VARIVAX . . . . . . . . . . . . . . . . . 86VARUBI . . . . . . . . . . . . . . . . . . 34VASERETIC . . . . . . . . . . . . . . . . 9VASOCIDIN . . . . . . . . . . . . . . . 51VASOCLEAR . . . . . . . . . . . . . . 51VASOCLEAR A . . . . . . . . . . . . 51VASOTEC . . . . . . . . . . . . . . . . . . 8VECTICAL . . . . . . . . . . . . . . . . 24VEETIDS . . . . . . . . . . . . . . . . . 40velaglucerase alfa solr . . . . . . 33VELTASSA . . . . . . . . . . . . . . . . 13VEMAVITE-PRX 2 . . . . . . . . . . 76vemurafenib . . . . . . . . . . . . . . . . 5VENA-BAL DHA . . . . . . . . . . . 75VENCLEXTA . . . . . . . . . . . . . . . 5venetoclax . . . . . . . . . . . . . . . . . 5venlafaxine . . . . . . . . . . . . . . . . 56

venlafaxine XR . . . . . . . . . . . . . 56VENTOLIN HFA . . . . . . . . . . . . 64VEPESID . . . . . . . . . . . . . . . . . . 7verapamil . . . . . . . . . . . . . .11, 18verapamil extended-release . . 11VERIO . . . . . . . . . . . . . . . . . . . . 31VERIO, VERIO FLEX, VERIO IQ,

VERIO SYNC . . . . . . . . . . . 31VERZENIO . . . . . . . . . . . . . . . . . 4VESANOID . . . . . . . . . . . . . . . . . 7VESICARE . . . . . . . . . . . . . . . . 67VFEND . . . . . . . . . . . . . . . . . . . 41VI-DAYLIN . . . . . . . . . . . . . . . . . 90VIBRAMYCIN, DOXY-100 . . . 40VICODIN . . . . . . . . . . . . . . . . . . 16VICODIN ES . . . . . . . . . . . . . . . 16VICOPROFEN . . . . . . . . . .16, 17VIDEX . . . . . . . . . . . . . . . . . . . . 43VIDEX EC . . . . . . . . . . . . . . . . . 43VIEKIRA PAK . . . . . . . . . . . . . . 41vigabatrin oral solution . . . . . . 20VIGAMOX . . . . . . . . . . . . . . . . . 53VIMPAT . . . . . . . . . . . . . . . . . . . 20VINATE AZ EX . . . . . . . . . . . . . 73VINATE DHA RF GELCAP . . . 77VINATE IC . . . . . . . . . . . . . . . . 77VINATE II . . . . . . . . . . . . . . . . . 73VIOKACE . . . . . . . . . . . . . . . . . 36VIRACEPT . . . . . . . . . . . . . . . . 43VIRAMUNE . . . . . . . . . . . . . . . 42VIRAMUNE XR . . . . . . . . . . . . 42VIREAD . . . . . . . . . . . . . . . . . . 43VIROPTIC . . . . . . . . . . . . . . . . . 54VIRT-BAL DHA COMBO

PACK . . . . . . . . . . . . . . . . . 75VIRT-C DHA . . . . . . . . . . . . . . . 73VIRT-PN . . . . . . . . . . . . . . . . . . 74VIRT-SELECT . . . . . . . . . . . . . 76VIRTPREX . . . . . . . . . . . . . . . . 76VISINE . . . . . . . . . . . . . . . . . . . 90VISINE-AC . . . . . . . . . . . . . . . . 51vismodegib . . . . . . . . . . . . . . . . 7VISTARIL . . . . . . . . . . . . . . . . . 27VISTOGARD . . . . . . . . . . . . . . 33VITAFOL ULTRA . . . . . . . . . . . 74VITAFOL-NANO . . . . . . . . . . . . 75

VITAFOL-OB+DHA . . . . . . . . . 72VITAFOL-ONE . . . . . . . . . . . . . 72VITAL-D RX . . . . . . . . . . . . . . . . 67VITAMAX PEDIATRIC . . . . . . . 71vitamin A . . . . . . . . . . . . . . . . . 78vitamin ADC/fluoride/±iron

drops . . . . . . . . . . . . . . . . . 78vitamin B complex/vitamin C/

folic acid . . . . . . . . . . . . . . . 78vitamin B-1 . . . . . . . . . . . . . . . . 78VITAMIN B-12 . . . . . . . . . . . . . 68vitamin B-6 . . . . . . . . . . . . . . . . 78vitamin C . . . . . . . . . . . . . . . . . 78VITAMIN D 1000 UNIT . . . . . . 68VITAMIN D 2000 UNIT . . . . . . 68vitamin D 400 IU . . . . . . . . . . . 90VITAMIN D 400 UNIT . . . . . . . 67VITAMIN K1 . . . . . . . . . . . . . . . 71vitamins pediatric . . . . . . .78, 90vitamins pediatric members

<3 years old . . . . . . . . . . . . 90vitamins prenatal . . . . . . . . . . . 90VITEKTA . . . . . . . . . . . . . . . . . . 42VIVA DHA . . . . . . . . . . . . . . . . . 74VIVACTIL . . . . . . . . . . . . . . . . . 56VIVELLE-DOT . . . . . . . . . . . . . 49VIVOTIF BERNA . . . . . . . . . . . 86VOLTAREN . . . . . . . . 15, 46, 51VOLTAREN 1% TOPICAL

GEL . . . . . . . . . . . . . . . . . . 46VOLTAREN XR . . . . . . . . .15, 46voriconazole . . . . . . . . . . . . . . 41vorinostat . . . . . . . . . . . . . . . . . . 4vortioxetine HBR . . . . . . . . . . . 57VOSOL HC OTIC . . . . . . . . . . 27VOSOL OTIC . . . . . . . . . . . . . . 26VOTRIENT . . . . . . . . . . . . . . . . . 5VP-ERA OB . . . . . . . . . . . . . . . 73VP-HEME ONE . . . . . . . . . . . . 73VP-HEME-OB . . . . . . . . . . . . . 73VP-PNV-DHA . . . . . . . . . . . . . . 74VPRIV . . . . . . . . . . . . . . . . . . . . 33VYVANSE . . . . . . . . . . . . . . . . 55VYVANSE CHEWABLE . . . . . 55

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Wwarfarin . . . . . . . . . . . . . . . . . . . 7water for inject, bacteriostatic

benzyl alcohol . . . . . . . . . . 84water for inject, bacteriostatic

parabens . . . . . . . . . . . . . . 84water for injection . . . . . . . . . . 84water for irrigation, sterile

soln . . . . . . . . . . . . . . . . . . . 84water for iv injection . . . . . . . . 84WELLBUTRIN . . . . . . . . . . . . . 57WELLBUTRIN SR . . . . . . . . . . 57WELLBUTRIN XL . . . . . . . . . . 57WESTCORT . . . . . . . . . . . . . . . 22WYTENSIN . . . . . . . . . . . . . . . 14

XXALATAN . . . . . . . . . . . . . . . . . 53XALKORI . . . . . . . . . . . . . . . . . . 4XANAX . . . . . . . . . . . . . . . . . . . 54XARELTO . . . . . . . . . . . . . . . . . . 7XELODA . . . . . . . . . . . . . . . . . . . 4XENAZINE . . . . . . . . . . . . . . . . 21XIIDRA . . . . . . . . . . . . . . . . . . . 53XODOL . . . . . . . . . . . . . . . . . . . 16XOPENEX RESPULES . . . . . . 65XULANE . . . . . . . . . . . . . . . . . . 49XYLOCAINE . . . . . . . . . . . .26, 28XYZAL . . . . . . . . . . . . . . . . . . . 27

YYASMIN . . . . . . . . . . . . . . . . . . 48YAZ . . . . . . . . . . . . . . . . . . . . . . 48YODEFAN-NF CHEST

CONGESTION . . . . . . . . . 61yuvafem or estradiol vaginal

tablet . . . . . . . . . . . . . . . . . 49

Zzafirlukast . . . . . . . . . . . . . . . . . 65zaleplon . . . . . . . . . . . . . . . . . . 57ZAMICET . . . . . . . . . . . . . . . . . 16ZANAFLEX . . . . . . . . . . . . . . . 47zanamivir . . . . . . . . . . . . . . . . . 42ZANTAC . . . . . . . . . . . . . . . . . . 35ZANTAC INJ . . . . . . . . . . . . . . 35

ZARONTIN . . . . . . . . . . . . . . . 19ZAROXOLYN . . . . . . . . . . . . . . 12ZARXIO . . . . . . . . . . . . . . . . . . . 8ZATEAN-CH CAPSULE . . . . . 75ZATEAN-PN . . . . . . . . . . . .74, 77ZATEAN-PN PLUS . . . . . . . . . 77ZAVESCA . . . . . . . . . . . . . . . . . 86ZEBETA . . . . . . . . . . . . . . . . . . 10ZEBUTAL . . . . . . . . . . . . . . . . . 15ZEJULA . . . . . . . . . . . . . . . . . . . 7ZELBORAF . . . . . . . . . . . . . . . . 5ZEMPLAR . . . . . . . . . . . . . . . . 71ZEMPLAR IV . . . . . . . . . . . . . . 71ZENPEP . . . . . . . . . . . . . . . . . . 36ZENTANE . . . . . . . . . . . . . . . . . 21ZERIT . . . . . . . . . . . . . . . . . . . . 43ZESTORETIC . . . . . . . . . . . . . . 9ZESTRIL . . . . . . . . . . . . . . . . . . . 9ZETIA . . . . . . . . . . . . . . . . . . . . 13ZIAC . . . . . . . . . . . . . . . . . . . . . 10ZIAGEN . . . . . . . . . . . . . . . . . . 43zidovudine . . . . . . . . . . . . . . . . 43zidovudine soln . . . . . . . . . . . . 43ZINACEF . . . . . . . . . . . . . . . . . 38ZINBRYTA . . . . . . . . . . . . . . . . 18zinc . . . . . . . . . . . . . . . 26, 51, 78zinc chloride inj soln . . . . . . . . 78ZINC SULFATE INJ . . . . . . . . . 78zinc sulfate inj soln . . . . . . . . . 78ZINC TRACE METAL INJ. . . . 78ZINGIBER . . . . . . . . . . . . . . . . 74ziprasidone . . . . . . . . . . . . . . . 58ZITHROMAX . . . . . . . . . . . . . . 39ZITHROMAX IV . . . . . . . . . . . . 39ZITHROMAX POWDER FOR

SUSP . . . . . . . . . . . . . . . . . 39ZOCOR. . . . . . . . . . . . . . . . . . . 13ZOFRAN . . . . . . . . . . . . . . . . . . 34ZOFRAN INJ . . . . . . . . . . . . . . 34ZOFRAN ODT . . . . . . . . . . . . . 34ZOHYDRO ER . . . . . . . . . . . . . 17zoledronic acid soln . . . . . . . . 32ZOLINZA . . . . . . . . . . . . . . . . . . 4ZOLOFT . . . . . . . . . . . . . . . . . . 56zolpidem . . . . . . . . . . . . . . . . . 57ZOMETA INJ . . . . . . . . . . . . . . 32

ZONALON . . . . . . . . . . . . . . . . 25ZONATUSS . . . . . . . . . . . . . . . 59ZONEGRAN . . . . . . . . . . . . . . 20zonisamide . . . . . . . . . . . . . . . 20ZORTRESS . . . . . . . . . . . . . . . . 6ZOSTAVAX . . . . . . . . . . . . . . . . 86zoster vaccine live . . . . . . . . . . 86ZOSYN . . . . . . . . . . . . . . . . . . . 40ZOVIA 1/35 . . . . . . . . . . . . . . . 48ZOVIA 1/50 . . . . . . . . . . . . . . . 49ZOVIRAX . . . . . . . . . . . . . . . . . 42ZUTRIPRO . . . . . . . . . . . . . . . . 63ZYBAN . . . . . . . . . . . . . . . . . . . 58ZYDELIG . . . . . . . . . . . . . . . . . . 5ZYKADIA . . . . . . . . . . . . . . . . . . 4ZYLET . . . . . . . . . . . . . . . . . . . 51ZYLOPRIM . . . . . . . . . . . . . . . . 46ZYPREXA . . . . . . . . . . . . . . . . 58ZYPREXA ZYDIS . . . . . . . . . . 58ZYRTEC . . . . . . . . . . . . . . .27, 87ZYRTEC CHEWABLE

TABLET . . . . . . . . . . . . . . . 27ZYRTEC D . . . . . . . . . . . . . . . . 87ZYRTEC-D . . . . . . . . . . . . . . . . 28ZYTIGA . . . . . . . . . . . . . . . . . . . 5ZYVOX . . . . . . . . . . . . . . . . . . . 44

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“My Medications” worksheetTake this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

Name of Medicine and Strength

Drug Tier

I Take This Medicine For Directions Doctor

Example: Lisinopril, 20mg Tier 1 High blood pressure One tablet daily Dr. Johnson

Download - Preferred Drug List (PDL) - uhccommunityplan.com€¦ · Preferred Drug List (PDL) ... If you think you were treated unfairly because of your sex, age, race, ... enviará la decisión

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