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Preferred Drug List (PDL) Ohio Ef f ective Date: 8 / 1/18 © 2018 United Healthcare Services, Inc. All rights reserved.

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Preferred Drug List (PDL)Ohio Ef f ective Date: 8 /1/18

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

UnitedHealthcare Community Plan of Ohio, Inc. no discrimina por motivos de sexo, edad, raza, color, discapacidad o nacionalidad.

Si considera que no hemos proporcionado estos servicios o hemos discriminado de otro modo en función del sexo, la edad, la raza, el color, la discapacidad o la nacionalidad, puede enviar una reclamación al Coordinador de derechos civiles.o En línea: [email protected] Por correo postal: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance.

P.O. Box 30608, Salt Lake City, UT 84130

Debe enviar la reclamación dentro de un plazo de 60 días desde que se enteró de la situación. Se le enviará una decisión dentro de un plazo de 30 días. Si no está de acuerdo con la decisión, tiene 15 días para pedirnos que analicemos la situación nuevamente. Si necesita ayuda con su reclamación, llame al 1-800-895-2017 (TTY 711), de 7 a. m. a 7 p. m., de lunes a viernes (correo de voz disponible las 24 horas del día, los 7 días de la semana).

También puede presentar una reclamación ante el Departamento de Salud y Servicios Humanos de los EE. UU. (U.S. Department of Health and Human Services).o En línea: https://ocrportal.hhs.gov/ocr/portal/lobby.jsfLos formularios de reclamación están disponibles en http://www.hhs.gov/ocr/office/file/index.html.o Por teléfono: línea gratuita 1-800-368-1019, 800-537-7697 (TDD)o Por correo postal: U.S. Dept. of Health and Human Services. 200 Independence Avenue,

SW Room 509F, HHH Building Washington, D.C. 20201

Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros, como cartas en otros idiomas o en letra grande. O bien, puede solicitar un intérprete. Para solicitar ayuda, llame a 1-800-895-2017 (TTY 711), de 7 a. m. a 7 p. m., de lunes a viernes (correo de voz disponible las 24 horas del día, los 7 días de la semana).

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call 1-800-895-2017, TTY 711.

ATENCIÓN: si habla español (Spanish), tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-895-2017, TTY 711.

注意:如果您說中文 (Chinese),您可獲得免費語言協助服務。請致電 1-800-895-2017,或聽障專線 (TTY) 711。

LƯU Ý: Nếu quý vị nói Tiếng Việt (Vietnamese), chúng tôi có các dịch vụ hỗ trợ ngôn ngữ miễn phí cho quý vị. Vui lòng gọi số 1-800-895-2017, TTY 711.

참고: 한국어(Korean)를 하시는 경우, 통역 서비스를 무료로 이용하실 수 있습니다. 1-800-895-2017, TTY 711 로 전화하십시오.

ATENSYON: Kung nagsasalita ka ng Tagalog (Tagalog), may magagamit kang mga serbisyo ng pantulong sa wika, nang walang bayad. Tumawag sa 1-800-895-2017, TTY 711.

CSOH15MC4045309_000

ВНИМАНИЕ: Если вы говорите по-русском (Russian), вы можете воспользоваться бесплатными услугами переводчика. Звоните по тел 1-800-895-2017, TTY 711.

تنبيه: إذا كنت تتحدث العربية (Arabic)، تتوفر لك خدمات المساعدة اللغوية مجاًنا. اتصل على الرقم 2017-895-800-1، الهاتف النصي 711.

ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nan 1-800-895-2017, TTY 711.

ATTENTION : Si vous parlez français (French), vous pouvez obtenir une assistance linguistique gratuite. Appelez le 1-800-895-2017, TTY 711.

UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod numer 1-800-895-2017, TTY 711.

ATENÇÃO: Se fala português (Portuguese), encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-895-2017, TTY 711.

ATTENZIONE: se parla italiano (Italian), Le vengono messi gratuitamente a disposizione servizi di assistenza linguistica. Chiami il numero 1-800-895-2017, TTY 711.

HINWEIS: Wenn Sie Deutsch (German) sprechen, stehen Ihnen kostenlose Sprachendienste zur Verfügung. Wählen Sie: 1-800-895-2017, TTY 711.

ご注意:日本語 (Japanese) をお話しになる場合は、言語支援サービスを無料でご利用いただけます。電話番号1-800-895-2017、またはTTY 711(聴覚障害者・難聴者の方用)までご連絡ください。

توجه: اگر زبان شما فارسی (Farsi) است، خدمات امداد زبانی به طور رایگان در اختیار شما می باشد. .TTY 711 ،2017-895-800-1 تماس بگیرید

ध्यान दें: ्दद आप हिन्दी (Hindi) भयाषया बोलत ेहैं तो भयाषया सहया्तया सेवयाएं आपके ललए ननःशुलक उपलब्ध हैं। कॉल करें 1-800-895-2017, TTY 711.

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau 1-800-895-2017, TTY 711.

ចំណាប់អារម្មណ៍៖ បបើសិនអ្នកនិយាយភាសាខ ម្ែរ (Khmer) បសវាជំនួយភាសាបោយឥតគិតថ ល្ៃ គឺមានសំរាប់អ្នក។ សូមទូរស័ព្ទបៅបេខ 1-800-895-2017។ TTY 711។

PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kaniam. Maidawat nga awagan iti 1-800-895-2017, TTY 711.

D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné ЁNavajoЂ Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-895-2017, TTY 711.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac 1-800-895-2017, TTY 711.

ध्यान ददनुहोस:् ्दद तपयाईं नेपालदी (Nepali) भयाषया बोलनुहुन्छ भने तपयाईंको लयागि नन:शुलक भयाषया सहया्तया सेवयाहरू उपलब्ध ्छन।् कृप्या 1-800-895-2017, TTY 711, मया फोन िनुनुहोस।्

XIYYEEFFANNOO: Afaan Kushaitii (Cushite) dubbattu yoo ta’e, tajaajilli gargaarsa afaanii, kanfaltii malee isiniif ni argama. Maaloo lak. 1-800-895-2017 n TTY 711 n bilbila’a.

LET OP: Als u Nederlands (Dutch) spreekt, kunt u gratis gebruikmaken van taalhulpdiensten. Bel 1-800-895-2017, TTY 711.

WICHTIG: Wann du Deitsch schwetzscht (Pennsylvania Dutch) un Hilf witt mit Englisch, kenne mer dich helfe, unni as es dich ennich ebbes koschte zellt. Ruf 1-800-895-2017, TTY 711 aa.

ATENȚIE: Dacă vorbiți limba română (Romanian), aveți la dispoziție servicii de asistență lingvistică gratuite. Sunați la 1-800-895-2017, TTY 711.

УВАГА: Якщо ви не говорите українською (Ukrainian) мовою, ви можете скористатися безкоштовними послугами перекладача. Телефонуйте за номером 1-800-895-2017, TTY 711.

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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.

2

Table of ContentsAntineoplastics & Immunosuppressants . . . 4Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . 4Hormonal Antineoplastic Agents. . . . . . . . . . . . . 5Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . 6Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . 6Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

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

Cardiovascular Agents . . . . . . . . . . . . . . . . . . 8Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Ace Inhibitor/Diuretic Combinations. . . . . . . . . . 8Adrenolytics, Central . . . . . . . . . . . . . . . . . . . . . . . 9Alpha Blockers. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Angiotensin II Receptor Blockers (Antagonists) . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Angiotensin II Receptor Blocker Combinations. . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antiarrhythmics and Cardiac Glycosides . . . . . . 9Beta Blockers and Beta Blocker/Diuretic Combinations. . . . . . . . . . . . . . . . . . . . . . . . . . . 9Calcium Channel Blockers. . . . . . . . . . . . . . . . . 10Calcium Channel Blockers/ACE Inhibitor Combination. . . . . . . . . . . . . . . . . . . . . . . . . . . 10Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Lipid Lowering Agents . . . . . . . . . . . . . . . . . . . . 11Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Potassium-Removing Agents . . . . . . . . . . . . . . . 12Pulmonary Arterial Hypertension . . . . . . . . . . . 12Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Central Nervous System. . . . . . . . . . . . . . . .13Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 13Amyotrophic Lateral Sclerosis (ALS) . . . . . . . . 13Analeptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 15Migraine Prophylactic Therapy . . . . . . . . . . . . . 15Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . 15Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . . 16Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 16Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . .18Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 18Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . 19Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 20Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Scabies and Pediculosis. . . . . . . . . . . . . . . . . . . 20Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . .22Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 23

Endocrinology . . . . . . . . . . . . . . . . . . . . . . . .24Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 24Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 24Growth Stimulating Agents. . . . . . . . . . . . . . . . . 26Lipodystropy Agents . . . . . . . . . . . . . . . . . . . . . . 26Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 26Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Gastrointestinal. . . . . . . . . . . . . . . . . . . . . . .27Constipation/Laxatives . . . . . . . . . . . . . . . . . . . . 27Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Emesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Gastroesophageal Reflux Disease (Gerd)/ Peptic Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . 28Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . . 28Inflammatory Bowel Disease . . . . . . . . . . . . . . . 29Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 29Probiotic Supplementation. . . . . . . . . . . . . . . . . 29Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Infectious Diseases . . . . . . . . . . . . . . . . . . .30Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Antiprotozoals. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

3

Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Musculoskeletal . . . . . . . . . . . . . . . . . . . . . .35Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 37

OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Hormone Therapy/Menopause. . . . . . . . . . . . . 38Ovulation Stimulants . . . . . . . . . . . . . . . . . . . . . . 39Vaginal Infections. . . . . . . . . . . . . . . . . . . . . . . . . 39Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . .40Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 40Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Immunologic Agents . . . . . . . . . . . . . . . . . . . . . . 42Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Psychiatric. . . . . . . . . . . . . . . . . . . . . . . . . . .42Alcohol Deterrents . . . . . . . . . . . . . . . . . . . . . . . . 42Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Attention Deficit Hyperactivity Disorder (ADHD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . 43Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Medications Coverable for Participating Behavioral Health Prescribers . . . . . . . . . . . . 45Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . . 47Psychoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . 48Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Respiratory Drugs. . . . . . . . . . . . . . . . . . . . .48Antitussives, Decongestants, Expectorants and Combinations . . . . . . . . . . . . . . . . . . . . . . 48Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Urological . . . . . . . . . . . . . . . . . . . . . . . . . . .53Symptomatic Benign Prostatic Hypertrophy . . 53Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Vitamins and Minerals . . . . . . . . . . . . . . . . .54Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . .57Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Antidotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 57Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 57Idiopathic Pulmonary Fibrosis (IPF) . . . . . . . . . 57Immune Thrombocytopenic Purpura . . . . . . . . 57Medical Devices. . . . . . . . . . . . . . . . . . . . . . . . . . 57Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . . 58Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

OTC MEDICATIONS . . . . . . . . . . . . . . . . . . .60Acne. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 60Cough/Cold Allergy. . . . . . . . . . . . . . . . . . . . . . . 60Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Earwax Removal Products . . . . . . . . . . . . . . . . . 61Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 61First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 62Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Motion Sickness. . . . . . . . . . . . . . . . . . . . . . . . . . 62Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Smoking Cessation Products . . . . . . . . . . . . . . 63Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . 63Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Index of Covered Drugs . . . . . . . . . . . . . . . .64

4

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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 CYCLOPHOSPH generic 1 inj 500 mg, PAcyclophosphamide 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 Inhibitorsabemaciclib VERZENIO brand 2 PA, 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

cabozantinibCABOMETYX COMETRIQ

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

5

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

everolimusAFINITORAFINITOR DISPERZ

brand 2 PA, SP

gefitinib IRESSA brand 2 PA, SPibrutinib 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 mesna MESNEX brand 2 SP, tabletsvenetoclax VENCLEXTA brand 2 PA, SPProteasome Inhibitors ixazomib NINLARO brand 2 PA, SPHormonal Antineoplastic AgentsAndrogen Biosynthesis Inhibitorsabiraterone ZYTIGA brand 2 PA, SPAntiandrogensbicalutamide CASODEX generic 1flutamide EULEXIN generic 1Antiestrogenstamoxifen NOLVADEX generic 1toremifene FARESTON brand 2Aromatase Inhibitorsanastrozole ARIMIDEX generic 1exemestane AROMASIN generic 1letrozole FEMARA generic 1

6

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Gonadotropin Releasing Hormone Analogleuprolide LUPRON generic 1 PA, SP

leuprolideLUPRON DEPOTLUPRON DEPOT 6-MONTHLUPRON DEPOT-PED

brand 2 PA, SP

Progestinmegestrol acetate MEGACE generic 1ImmunomodulatorsInterferonsinterferon gamma-1b ACTIMMUNE brand 2 PA, SP

interferon alfa-2b INTRON A brand 2 3,000,000 unit/0.2 ML only, PA, SP

peginterferon alfa-2b SYLATRON brand 2 PA, SPMiscellaneouslenalidomide REVLIMID brand 2 PA, SPpomalidomide POMALYST brand 2 PA, SPImmunosuppressantsAntimetabolitesazathioprine IMURAN generic 1mycophenolate mofetil CELLCEPT generic 1mycophenolate sodium MYFORTIC generic 1Calcineurin Inhibitorscyclosporine SANDIMMUNE generic 1

cyclosporine, modifiedGENGRAF NEORAL

generic 1 caps, QL

tacrolimusHECORIA PROGRAF

generic 1

Othereverolimus ZORTRESS brand 2Rapamycin Derivativesirolimus RAPAMUNE generic 1 tabssirolimus RAPAMUNE brand 2 solnMiscellaneousalitretinoin 1% gel PANRETIN brand 2 PAbexarotene caps and

topical gel TARGRETIN brand 2 PA, SP

cysteamine bitartrate CYSTAGON brand 2 SPetoposide VEPESID generic 1hydroxyurea DROXIA brand 2hydroxyurea HYDREA generic 1

7

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

leucovorin calcium WELLCOVORIN generic 1mitotane LYSODREN brand 2 PAniraparib ZEJULA brand 2 PA, SPoctreotide SANDOSTATIN generic 1 PA, SPolaparib LYNPARZA brand 2 PA, SPpasireotide SIGNIFOR brand 2 PA, SPprocarbazine MATULANE brand 2 SPrucaparib RUBRACA brand 2 PA, SP sonidegib ODOMZO brand 2 PA, SPthalidomide THALOMID brand 2 PA, SPtopotecan HYCAMTIN brand 2 PA, SPtretinoin VESANOID generic 1 caps, SPvismodegib ERIVEDGE brand 2 PA, SP

Blood Modifiers - Anticoagulants

Anticoagulantsapixaban ELIQUIS brand 2 QLbetrixaban BEVYXXA brand 2 QLedoxaban 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

rivaroxaban XARELTO brand 2 QLwarfarin generic 1Blood Cell Formationdarbepoetin alfa ARANESP brand 2 PA, SP

epoetin alfaEPOGENPROCRIT

brand 2 PA, SP

filgrastim ZARXIO brand 2 PA, SPoprelvekin NEUMEGA brand 2 PA, SPpegfilgrastim NEULASTA brand 2 PA, SPplerixafor MOZOBIL brand 2 PA, SPsargramostim LEUKINE brand 2 PA, SPPlatelet Inhibitorsanagrelide AGRYLIN generic 1

aspirinBAYER

ECOTRINgeneric 1 OTC

8

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

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

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.fosinopril MONOPRIL generic 1 QLlisinopril ZESTRIL generic 1 QLmoexipril hcl UNIVASC generic 1perindopril erbumine ACEON generic 1quinapril 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

9

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

moexipril- hydrochlorothiazide UNIRETIC generic 1

quinapril/ hydrochlorothiazide ACCURETIC generic 1 QL

Adrenolytics, Centralclonidine CATAPRES generic 1clonidine transdermal CATAPRES- TTS generic 1guanfacine TENEX generic 1Alpha Blockersdoxazosin CARDURA generic 1prazosin MINIPRESS generic 1terazosin HYTRIN generic 1Angiotensin II Receptor Blockers (Antagonists)losartan COZAAR generic 1 QLAngiotensin II Receptor Blocker Combinationslosartan/HCTZ HYZAAR generic 1 QLsacubitril/valsartan ENTRESTO brand 2 PA, QLAntiarrhythmics and Cardiac Glycosidesamiodarone tabs CORDARONE generic 1 200 mg and 400 mgdigoxin LANOXIN generic 1disopyramide NORPACE generic 1disopyramide

extended-release NORPACE CR brand 2

dofetilide TIKOSYN generic 1flecainide TAMBOCOR generic 1mexiletine MEXITIL generic 1propafenone RYTHMOL generic 1 IR onlyquinidine gluconate

extended-releaseQUINIDINE GLUCONATE

EXT-REL generic 1

quinidine sulfate QUINIDINE SULFATE generic 1quinidine sulfate

extended-releaseQUINIDINE SULFATE

EXT-REL generic 1

Beta 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 QL

10

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

labetalol TRANDATE generic 1metoprolol LOPRESSOR generic 1 25, 50, 100mg tabletsmetoprolol succinate TOPROL XL generic 1nadolol CORGARD generic 1propranolol INDERAL generic 1propranolol ER 24hr INDERAL LA generic 1 Diagnosis Required, QLpropranolol/HCTZ INDERIDE generic 1sotalol BETAPACE generic 1sotalol 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 extended-release

DILACOR XR TIAZAC

generic 1 QL

diltiazem sustained-release CARDIZEM SR generic 1 QL

verapamil CALAN generic 1verapamil

extended-release CALAN SR generic 1 QL

Calcium Channel Blockers/ACE Inhibitor Combinationamlodipine-benazepril LOTREL generic 1Diureticsamiloride MIDAMOR generic 1amiloride/

hydrochlorothiazide MODURETIC generic 1

bumetanide BUMEX generic 1chlorothiazide DIURIL generic 1

11

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

chlorothiazide DIURIL ORAL SUSPENSION brand 2 QL

chlorthalidone CHLORTHALIDONE generic 1furosemide LASIX generic 1hydrochlorothiazide HYDROCHLOROTHIAZIDE generic 1 soln, tabshydrochlorothiazide MICROZIDE generic 1 12.5 mg capsindapamide LOZOL generic 1metolazone ZAROXOLYN generic 1spironolactone ALDACTONE generic 1spironolactone/

hydrochlorothiazide ALDACTAZIDE generic 1

torsemide DEMADEX generic 1triamterene/

hydrochlorothiazideDYAZIDEMAXZIDE

generic 1

Lipid Lowering AgentsBile Acid Resin

cholestyramineQUESTRANQUESTRAN-LIGHT

generic 1

Only the bulk products are covered (cans).

Individual packets are not covered.

Fibratesfenofibrate LIPOFEN brand 2 cap, PAfenofibrate LOFIBRA generic 1 STgemfibrozil LOPID generic 1HMG-CoA Reductase Inhibitors and Combinationsatorvastatin LIPITOR generic 1 QLlovastatin MEVACOR generic 1 QLsimvastatin ZOCOR generic 1 QLOthersfish oil caps FISH OIL generic 1 OTCinositol niacinate NIACINOL generic 1 500 mg caps only, OTCNiacinsniacin NIACOR generic 1niacin extended-release NIASPAN generic 1Miscellaneousalirocumab PRALUENT brand 2 PA, QL, SPezetimibe ZETIA generic 1 PAomega 3 acid

ethyl esters LOVAZA generic 1 PA

12

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

NitratesOralisosorbide dinitrate ISORDIL generic 1isosorbide dinitrate

extended-releaseISOSORBIDE

DINITRATE ER generic 1

isosorbide mononitrate ISMO generic 1isosorbide mononitrate

extended-release IMDUR generic 1

Sublingualisosorbide dinitrate ISORDIL S.L. generic 1nitroglycerin NITROLINGUAL generic 1nitroglycerin NITROSTAT generic 1Transdermal

nitroglycerinNITREK NITRO-DUR

generic 1 transdermal, not 0.3 mg or 0.8 mg, QL

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

sulfonate KALEXATE generic 1 powder

sodium 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

sildenafil REVATIO generic 1 Diagnosis Required, SP, tablets

sildenafil REVATIO SUSPENSION brand 2 Diagnosis Required, SP, suspension

Miscellaneousguanabenz WYTENSIN generic 1hydralazine APRESOLINE generic 1methyldopa ALDOMET generic 1methyldopa/HCTZ ALDORIL generic 1midodrine PROAMATINE generic 1minoxidil LONITEN generic 1ranolazine RANEXA brand 2 ST

13

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

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.

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 1

PA req for soln, QL, Members <18 years of age will require prior

authorization.Amyotrophic Lateral Sclerosis (ALS)riluzole RILUTEK brand 2Analepticsarmodafinil NUVIGIL generic 1 Diagnosis RequiredAnalgesicsBarbiturate Non-Narcotic Analgesicsbutalbital/acetaminophen PHRENILIN generic 1 capsule, QLbutalbital/acetaminophen/

caffeine ESGIC generic 1 QL

butalbital/aspirin/caffeine FIORINAL generic 1 QLNon-Narcotic Analgesicsacetaminophen TYLENOL generic 1 OTCaspirin/acetaminophen/

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

tramadol ULTRAM generic 1 QLNSAIDSdiclofenac potassium CATAFLAM generic 1diclofenac sodium

delayed-release VOLTAREN generic 1 QL

14

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

diclofenac sodium extended-release VOLTAREN XR generic 1

etodolac LODINE generic 1

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

ibuprofen MOTRIN generic 1 tabs, chew tabs and susp

indomethacin INDOCIN generic 1ketoprofen ORUDIS generic 1ketorolac tromethamine TORADOL generic 1 QLmeloxicam MOBIC generic 1 QLnaproxen NAPROSYN generic 1

naproxen delayed release ENTERIC COATED-NAPROSYN generic 1

oxaprozin DAYPRO generic 1piroxicam FELDENE generic 1sulindac CLINORIL generic 1Opioids — Narcotic Analgesicsbutalbital/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, QL

hydrocodone/ acetaminophen

LORCETLORTABLORTAB ELIXIRNORCOVICODINVICODIN ES

generic 1 QL

hydrocodone ER ZOHYDRO ER brand 2 PAhydromorphone DILAUDID generic 1 QLmeperidine DEMEROL generic 1 QLmorphine MSIR generic 1 QLmorphine RMS generic 1 PA, QLmorphine

extended-release MS CONTIN generic 1 PA, QL

oxycodone OXYFAST generic 1 soln, QL

15

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

oxycodone ROXICODONE generic 1 5mg, 10mg, 15mg, 20mg, 30mg, QL

oxycodone/ acetaminophen PERCOCET generic 1 5/325 mg, 7.5/325 mg,

10/325 mg, QLoxycodone/aspirin PERCODAN generic 1 QL

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

pentazocine/naloxone TALWIN NX generic 1 QLMigraine Acute TherapyErgotamine Derivativesdihydroergotamine D.H.E. 45 generic 1 inj, QLergotamine/caffeine CAFERGOT generic 1ergotamine tartrate/

caffeineMIGERGOT

SUPPOSITORIES brand 2 QL

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

sumatriptan-naproxen TREXIMET brand 2 PAMigraine 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

16

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

glatiramer acetate GLATOPA generic 1 Diagnosis Required, QL, SP

peginterferon beta-1a PLEGRIDY generic 1 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

Parkinson’s Diseaseamantadine SYMMETREL generic 1 except tabsbenztropine COGENTIN generic 1carbidopa/levodopa SINEMET generic 1carbidopa/levodopa

extended-release SINEMET CR generic 1

entacapone COMTAN generic 1pramipexole MIRAPEX generic 1ropinirole 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 tabs, PAclonazepam KLONOPIN generic 1 tabsdiazepam DIASTAT ACUDIAL generic 1 rectal gel, QL

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

ethosuximide ZARONTIN generic 1ezogabine POTIGA brand 2 Age Limits Applyfelbamate FELBATOL generic 1 QL

17

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

felbamate oral susp FELBATOL ORAL SUSP generic 1

QL, suspension, Members ≥ 8 years of age will require prior

authorization. gabapentin NEURONTIN generic 1 caps and tabs onlylacosamide VIMPAT brand 2 Age Limits Apply*lamotrigine LAMICTAL generic 1 not chewable, QL

lamotrigine chew dispersable tab LAMICTAL CD CHEW TAB generic 1

Members ≥ 8 years of age will require prior

authorization.lamotrigine starter kit LAMICTAL STARTER KIT brand 2

levetiracetam KEPPRA (NOT XR) generic 1 QL, Maximum age of 9 for solution

methsuximide 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, 2mg & 4mg*

tiagabine GABITRIL brand 2 Age Limits Apply, 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 QLMiscellaneoustetrabenazine XENAZINE generic 1 Diagnosis Required, SPvalbenazine INGREZZA brand 2 PA, QL

18

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Dermatology

Acne VulgarisOral

isotretinoin

ABSORICAAMNESTEEMCLARAVISMYORISANZENTANE

generic 1 PA

Topicaladapalene gel DIFFERIN OTC GEL 0.1% brand 2azelaic acid FINACEA brand 2 gelbenzoyl peroxide BENZAC AC generic 1clindamycin 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 solnerythromycin/benzoyl

peroxideBENZAMYCIN

generic 1

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

sulfacetamide/sulfur SULFACET-R generic 1 lotionsulfacetamide sodium

lotion KLARON generic 1

sulfacetamide/sulfur PLEXION generic 1 PA

tretinoinAVITA RETIN-A

generic 1 cream, ST

Bacterial Infectionsbacitracin BACITRACIN generic 1 OTCgentamicin GENTAK generic 1

mupirocin BACTROBAN generic 1 ointment, 22 gram tube only

neomycin/polymyxin B/bacitracin NEOSPORIN generic 1 OTC

silver sulfadiazine SILVADENE generic 1

19

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

CorticosteroidsLow 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 crm 0.5%, 1%, & 2.5%hydrocortisone HYTONE generic 1 lotion 1% & 2.5%

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

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% hydrocortisone valerate WESTCORT generic 1 crm 0.2%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 crm/gel/oint/soln 0.05%halobetasol ULTRAVATE generic 1 cream

20

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Fungal Infectionsciclopirox PENLAC SOLUTION 8% generic 1clotrimazole LOTRIMIN AF generic 1 OTCclotrimazole MYCELEX generic 1clotrimazole with

betamethasone LOTRISONE generic 1

ketoconazole NIZORAL generic 1miconazole DESENEX generic 1 2% OTCmiconazole MICATIN generic 1 OTCmiconazole MONISTAT-DERM generic 1nystatin MYCOSTATIN generic 1terbinafine LAMISIL AT generic 1 OTCtolnaftate TINACTIN generic 1 OTCPsoriasisacitretin SORIATANE generic 1 oral caps, PAcalcipotriene DOVONEX generic 1calcitriol VECTICAL generic 1 STsalicylic acid SCALPICIN generic 1 liquid 3%Rosaceabrimonidine MIRVASO brand 2 PA

metronidazoleMETROCREAMMETROGELMETROLOTION

generic 1

Scabies and Pediculosiscrotamiton EURAX brand 2malathion OVIDE generic 1 QLpermethrin ELIMITE generic 1 5%, QLpermethrin NIX CREME RINSE generic 1 1%, OTCpyrethrins/piperonyl

butoxide shampoo RID SHAMPOO generic 1 4% OTC

spinosad NATROBA generic 1Viral Infectionspodofilox 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

21

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

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

ammonium lactate LACTINOL generic 1 lotion 10%becaplermin gel REGRANEX brand 2 PAcalamine brand 2 lotion/ointment, OTCcollagenase oint SANTYL brand 2 QLcrisaborole EUCRISA brand 2 2% ointment, QL, STfluorouracil EFUDEX generic 1

hydrocortisone

PROCTOSOL HC CREAM 2.5%

PROCTOZONE CREAM-HC 2.5%

ANUSOL HC 2.5%

generic 1

imiquimod 5% cream ALDARA generic 1ketoconazole NIZORAL SHAMPOO generic 1 shampoo 2%lidocaine LIDAMANTEL generic 1 3% cream

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

lidocaine XYLOCAINE generic 1 jelly 2%lidocaine patch LIDODERM generic 1 Diagnosis Requiredlidocaine/prilocaine EMLA generic 2.5% cream

nitroglycerin RECTIV brand 2 Diagnosis Required, 0.4% rectal ointment

pimecrolimus ELIDEL brand 2

cream, QL, ST; not covered for members less

than 2 years of age

selenium sulfide SELSUN generic 1 lotion 2.5%

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% CREAMUREA 20% CREAMUREA 10% LOTION

brand 2

urea 40% UREA 40% LOTION generic 1 lotion

22

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

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

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

dexamethasone CIPRODEX brand 2 Diagnosis Required

neomycin/polymyxin B/hydrocortisone CORTISPORIN OTIC generic 1 otic

ofloxacin FLOXIN OTIC generic 1NoseAntihistamines - First Generation, Sedatingchlorpheniramine

extended-releaseCHLOR-TRIMETON

ALLERGY generic 1 12 mg, OTC

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

clemastine CLEMASTINE generic 1cyproheptadine CYPROHEPTADINE generic 1diphenhydramine generic 1diphenhydramine BENADRYL generic 1 OTChydroxyzine HCL ATARAX generic 1hydroxyzine pamoate VISTARIL generic 1Antihistamines - Second Generation, Nonsedatingcetirizine ZYRTEC generic 1 OTC

cetirizine chew tab ZYRTEC CHEWABLE TAB-LET 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 spray

23

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Antihistamine/Decongestant Combinations - First Generationchlorpheniramine/

phenylephrine/ pyrilamine

TRIOTANN generic 1

chlorpheniramine/ pseudoephedrine ACTIFED generic 1 OTC

diphenhydramine- phenylephrine soln BENADRYL-D brand 2 OTC

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/SINUSALLERGY/CONG

generic 1 OTC

Nasal Steroidsfluticasone FLONASE generic 1

triamcinolone nasal spray NASACORT ALLERGY 24 HOUR brand 2 OTC

Miscellaneous Nasal Decongestantsoxymetazoline AFRIN generic 1 OTC

phenylephrineNEO-SYNEPHRINE DIMEATAPP DRO

DECONGESgeneric 1 OTC

Miscellaneous Nasalcromolyn sodium NASALCROM generic 1 OTCipratropium nasal ATROVENT NASAL SPRAY generic 1 QLsaline nasal spray 0.65% OCEAN NASAL SPRAY generic 1 OTCThroat and Mouthchlorhexidine gluconate PERIDEX generic 1lidocaine viscous XYLOCAINE generic 1pilocarpine SALAGEN generic 1triamcinolone KENALOG IN ORABASE generic 1 paste

24

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Endocrinology

Adrenal Corticosteroidscortisone acetate generic 1dexamethasone DECADRON generic 1fludrocortisone FLORINEF generic 1hydrocortisone CORTEF generic 1methylprednisolone MEDROL generic 1 4mg, 8mg, 16mg, 32mgmethylprednisolone MEDROL brand 2 2mgprednisoloneprednisolone PRELONE generic 1 syrupprednisolone sodium

phosphateORAPREDPEDIAPRED

generic 1

prednisone DELTASONE generic 1Androgenstestosterone cypionate DEPO-TESTOSTERONE generic 1

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

testosterone gel topical tube, packet, and pump bottle

TESTOSTERONE 1% TOPICAL GEL generic 1 PA

Diabetes MellitusGlucose Elevating Agentsglucagon, human

recombinant GLUCAGON brand 2 QL

Insulin Combinationsinsulin glargine/lixisenatide SOLIQUA brand 2 STInsulinsinsulin aspart

protamine 70%/ insulin aspart 30%

NOVOLOG MIX 70/30 brand 2 QL, vials

insulin glargine BASAGLAR brand 2insulin glargine

300 unit/ml TOUJEO SOLOSTAR brand 2

insulin humanNOVOLIN RRELION R

brand 2 OTC, QL, vials

insulin isophane HUMULIN N brand 2 OTC, QL, vials

insulin isophane humanNOVOLIN NRELION N

brand 2 OTC, QL, vials

25

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

insulin 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 regular HUMULIN R brand 2 OTC, QL, vialsMonitoring - 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 Agentsacarbose PRECOSE generic 1alogliptin NESINA generic 1 STalogliptin/metformin KAZANO generic 1 STalogliptin/pioglitazone OSENI generic 1 STchlorpropamide DIABINESE generic 1ertugliflozin STEGLATRO brand 2 QL, STertugliflozin/metformin SEGLUROMET brand 2 QL, STglimepiride AMARYL generic 1glipizide GLUCOTROL generic 1glipizide extended-release GLUCOTROL XL generic 1glipizide-metformin METAGLIP generic 1glyburide MICRONASE generic 1glyburide, micronized GLYNASE generic 1metformin GLUCOPHAGE generic 1metformin ER GLUCOPHAGE ER generic 1metformin/glyburide GLUCOVANCE generic 1nateglinide STARLIX generic 1pioglitazone ACTOS generic 1 QLrepaglinide PRANDIN generic 1tolazamide TOLINASE generic 1tolbutamide TOLBUTAMIDE generic 1

26

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Miscellaneous Antidiabetic Agentsalbiglutide TANZEUM brand 2 STdulaglutide TRULICITY brand 2 STlixisenatide ADLYXIN brand 2 STpramlintide SYMLINPEN 60 brand 2 PAGrowth Stimulating Agentsmecasermin INCRELEX brand 2 PA, SPsomatropin ZOMACTON brand 2 PA, SPLipodystropy Agentstesamorelin EGRIFTA brand 2 Diagnosis Required, SPOsteoporosisabaloparatide inj TYMLOS brand 2 PA, SPalendronate FOSAMAX generic 1 QLcalcitonin-salmon MIACALCIN generic 1 nasal spray, QLcalcitonin-salmon FORTICAL brand 2 nasal spray, QLetidronate DIDRONEL generic 1raloxifene EVISTA generic 1Thyroid Diseaselevothyroxine LEVOXYL generic 1levothyroxine SYNTHROID generic 1liothyronine CYTOMEL generic 1liotrix THYROLAR brand 2methimazole TAPAZOLE generic 1propylthiouracil PROPYLTHIOURACIL generic 1Miscellaneousasfotase alfa STRENSIQ brand 2 PA, SPcabergoline DOSTINEX generic 1cholic acid CHOLBAM brand 2 PA, SPdesmopressin DDAVP generic 1 QLdesmopressin acetate inj DDAVP generic 1 4 mcg/ml, PAmethylergonovine METHERGINE generic 1mifepristone KORLYM brand 2 PA, SP

nitisinone NITYR brand 2 Diagnosis Required, QL, SP

pegvisomant SOMAVERT brand 2 PA, SPsapropterin KUVAN brand 2 Diagnosis Required, SP

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

uridine VISTOGARD brand 2

27

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Gastrointestinal

Constipation/Laxativescasanthranol-docusate

sodium generic 1 OTC

docusate calcium plus generic 1 OTCdocusate potasssium generic 1 OTCdocusate sodium DOK generic 1 100 mg tabs only, OTCdocusate sodium COLACE generic 1 OTCglycerin GLYCERIN SUPPOSITORY generic 1 suppository, OTClinaclotide LINZESS brand 2 Diagnosis Required, QLlactulose ENULOSE generic 1

magnesium citrate soln MAGNESIUM CITRATE SOLN generic 1

peg 3350/electrolytes COLYTE generic 1peg 3350/sodium

bicarbonate/sodium chloride

TRILYTE generic 1

peg 3350/sodium bicarbonate/sodium chloride/potassium chloride

NULYTELY generic 1

polyethylene glycol 3350 MIRALAX generic 1sennosides SENOKOT generic 1 8.6 mg tab, OTCDiarrheacrofelemer MYTESI brand 2 Diagnosis Requireddiphenoxylate/atropine LOMOTIL generic 1loperamide IMODIUM A-D generic 1 OTCloperamide LOPERAMIDE generic 1Emesisaprepitant EMEND generic 1 QL applies to 40 mg, 80

mg and 80-125 mgdronabinol MARINOL generic 1 PAmeclizine ANTIVERT generic 1metoclopramide REGLAN generic 1

ondansetronZOFRANZOFRAN ODT

generic 1 QL

prochlorperazine COMPAZINE generic 1promethazine PHENERGAN generic 1

28

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

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 1esomeprazole NEXIUM 24HR OTC brand 2 PA

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.lansoprazole PREVACID generic 1

lansoprazole delayed-release PREVACID SOLUTAB generic 1

orally disintegrating tabs, Members ≥ 2 years

of age will require priorauthorization. QL

omeprazole delayed-release PRILOSEC generic 1 Capsules only, QL

pantoprazole PROTONIX generic 1ranitidine ZANTAC generic 1 150 mg tabsranitidine 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 authorization.Gastrointestinal Spasmdicyclomine BENTYL generic 1 tablets onlyglycopyrrolate ROBINUL generic 1hyoscyamine sulfate LEVSIN generic 1hyoscyamine sulfate

extended-release LEVSINEX generic 1

29

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Inflammatory Bowel Diseasebalsalazide COLAZAL generic 1budesonide ENTOCORT EC generic 1 Diagnosis Requiredhydrocortisone COLOCORT generic 1 enemamesalamine ROWASA generic 1 enema onlymesalamine

extended-releaseAPRISODELZICOL

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

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

probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

brand 2 OTC

30

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Miscellaneousatropine sulfate SAL-TROPINE brand 2misoprostol CYTOTEC generic 1naloxegol MOVANTIK brand 2 Diagnosis Requiredteduglutide 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

pyrantel pamoate PIN-X brand 2 chewable tablets, suspension

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

AntibacterialsAntituberculosis Agentsaminosalicyclic acid PASER brand 2cycloserine SEROMYCIN generic 1ethambutol MYAMBUTOL generic 1ethionamide TRECATOR brand 2isoniazid ISONIAZID generic 1pyrazinamide PYRAZINAMIDE generic 1rifabutin MYCOBUTIN generic 1rifapin RIFADIN generic 1rifapentine PRIFTIN brand 2Cephalosporins - First Generationcefadroxil DURICEF generic 1

cephalexin KEFLEX generic 1 tabs are not covered, not 750 mg caps

Cephalosporins - Second Generationcefaclor CECLOR generic 1cefprozil CEFZIL generic 1cefuroxime axetil CEFTIN generic 1 tabs

31

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

cefuroxime axetil CEFTIN brand 2 suspensionCephalosporins - Third Generationcefdinir OMNICEF generic 1cefixime SUPRAX brand 2 400 mg caps only, QLFluoroquinolonesciprofloxacin CIPRO generic 1levofloxacin LEVAQUIN brand 2 tablets onlyofloxacin FLOXIN generic 1 tabsMacrolidesazithromycin ZITHROMAX generic 1 QLclarithromycin BIAXIN generic 1clarithromycin ER BIAXIN XL generic 1erythromycin delayed-

release ERYC generic 1

erythromycin delayed-release ERY-TAB brand 2

erythromycin ethylsuccinate E.E.S. generic 1

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 1ampicillin PRINCIPEN generic 1dicloxacillin DICLOXACILLIN generic 1penicillin VK VEETIDS generic 1Sulfonamidessulfamethoxazole/

trimethoprim, DSBACTRIMBACTRIM DS generic 1

Tetracyclinesdoxycycline hyclate VIBRAMYCIN generic 1 50 mg caps, 100 mg caps,

100 mg tabs, QL

doxycycline monohydrate DOXYCYCLINE MONOHYDRATE generic 1 caps only

minocycline MINOCIN generic 1 capsulestetracycline SUMYCIN generic 1 caps

32

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Miscellaneousvancomycin HCl VANCOCIN HCL generic 1 cap, STAntifungalsclotrimazole MYCELEX generic 1 trochesfluconazole DIFLUCAN generic 1 QLgriseofulvin 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 cream only, QLterbinafine LAMISIL AT SPRAY brand 2 soln 1%, PA, OTCvoriconazole VFEND generic 1 PAAntiprotozoalsatovaquone MEPRON generic 1benznidazole BENZNIDAZOLE brand 2 PA, QLmiltefosine IMPAVIDO brand 2 PA

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

authorization.pentamidine isethionate

for nebulization NEBUPENT brand 2

ALINIA brand 2 PAAntiviralsCytomegalovirus Treatmentganciclovir CYTOVENE generic 1valganciclovir VALCYTE generic 1 tabs onlyHepatitis Treatmententecavir BARACLUDE generic 1 SP

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

Genotypes 1, 2, 3, 4, 5, & 6

interferon alfa-2b INTRON A brand 2 PA, SPlamivudine EPIVIR HBV generic 1 tabs, SP, QLlamivudine EPIVIR HBV brand 2 solution, SP, QLpeginterferon alfa-2a PEGASYS brand 2 PA, SPpeginterferon alfa-2a PEGASYS PROCLICK brand 2 PA, SP

ribavirinREBETOLCOPEGUS

generic 1 200 mg caps and tabs only, PA, SP

33

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Herpes Treatmentacyclovir ZOVIRAX generic 1 caps, tabs, suspensiondocosanol ABREVA OTC CREAM brand 2valacyclovir VALTREX generic 1Influenza Treatmentamantadine SYMMETREL generic 1 except tabsoseltamivir TAMIFLU generic 1 capsules, QLrimantadine FLUMADINE generic 1zanamivir RELENZA brand 2 QLIntegrase Inhibitorsdolutegravir TIVICAY brand 2 Diagnosis requiredraltegravir ISENTRESS brand 2 Diagnosis required

raltegravir ISENTRESS CHEWABLE brand 2 Chewable tablet; Diagnosis required

raltegravir ISENTRESS HD brand 2

raltegravir susp ISENTRESS SUSP brand 2

Members ≥ 2 years ofage will require prior

authorization; Diagnosis Required

Nucleoside Reverse Transcriptase Inhibitors and Combinations – Diagnosis Requiredabacavir 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 1Nucleoside/Nucleotide Reverse Transcriptase Inhibitor Combination – Diagnosis Requiredefavirenz/emtricitabine/

tenofovir ATRIPLA brand 2

emtricitabine/rilpivirine/tenofovir ODEFSEY brand 2

emtricitabine/tenofovir TRUVADA brand 2

34

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

emtricitabine/tenofovir alafenamide DESCOVY brand 2 QL

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

atazanavir REYATAZ POWDER PACKET brand 2

Members ≥ 8 years of age will require prior

authorizationdarunavir PREZISTA brand 2fosamprenavir LEXIVA brand 2indinavir CRIXIVAN brand 2lopinavir/ritonavir KALETRA brand 2 tabletslopinavir/ritonavir KALETRA generic 1 solutionnelfinavir VIRACEPT brand 2ritonavir NORVIR brand 2saquinavir mesylate INVIRASE brand 2tipranavir APTIVUS brand 2Reverse Transcriptase Inhibitors – Diagnosis Requireddelavirdine RESCRIPTOR brand 2efavirenz SUSTIVA brand 2etravirine INTELENCE brand 2nevirapine VIRAMUNE generic 1nevirapine ER VIRAMUNE XR brand 2rilpivirine EDURANT brand 2Miscellaneousabacavir/dolutegravir/

lamivudine TRIUMEQ brand 2 Diagnosis required

cobicistat TYBOST brand 2 Diagnosis requiredcobicistat/elvitegravir/

emtricitabine/tenofovir STRIBILD brand 2 PA

darunavir/cobicistat PREZCOBIX brand 2 Diagnosis requireddolutegravir/rilpivirine JULUCA brand 2elvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate

GENVOYA brand 2 PA

enfuvirtide FUZEON brand 2maraviroc SELZENTRY brand 2 Diagnosis required

35

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Miscellaneousbedaquiline SIRTURO brand 2chloroquine phosphate ARALEN generic 1clindamycin CLEOCIN generic 1 150 mg and 300 mg onlydapsone DAPSONE brand 2hydroxychloroquine PLAQUENIL generic 1linezolid ZYVOX generic 1 PAmefloquine LARIAM generic 1metronidazole FLAGYL generic 1 tabs onlyneomycin sulfate brand 2nitrofurantoin

extended-release MACROBID generic 1

nitrofurantoin macrocrystals MACRODANTIN generic 1

nitrofurantoin susp FURADANTIN SUSP 25 MG/5 ML generic 1

Members ≥ 8 years of age will require prior

authorization.palivizumab SYNAGIS brand 2 PA, SPparomomycin HUMATIN generic 1povidone-iodine generic 1 OTCprimaquine generic 1pyrimethamine DARAPRIM brand 2 PA, SPtrimethoprim TRIMETHOPRIM generic 1 tabs only

Musculoskeletal

ArthritisDisease Modifying Anti-Rheumatic Drugsadalimumab HUMIRA brand 2 PA, SPanakinra KINERET brand 2 PA, SPapremilast OTEZLA brand 2 PA, SPauranofin RIDAURA brand 2azathioprine IMURAN generic 1canakinumab ILARIS brand 2 PA, SPcertolizumab pegol CIMZIA brand 2 PA, SPetanercept ENBREL brand 2 PA, SPhydroxychloroquine PLAQUENIL generic 1leflunomide ARAVA generic 1methotrexate generic 1penicillamine DEPEN TITRATABLE brand 2 Diagnosis Required, SPsarilumab KEVZARA brand 2 PA, QL, SP

36

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

secukinumab COSENTYX brand 2 PA, SPsulfasalazine AZULFIDINE generic 1sulfasalazine

delayed-release AZULFIDINE EN-TABS generic 1

NSAIDs and Other Analgesicsacetaminophen TYLENOL generic 1 OTC

aspirinBAYERECOTRIN

generic 1 OTC

capsaicinCAPSAGELCAPZASIN-PCASTIVA

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 CATALFAM generic 1diclofenac sodium

delayed-release VOLTAREN generic 1 QL

diclofenac sodium extended-release VOLTAREN XR generic 1

diflunisal DOLOBID generic 1 500 mg tabs onlyetodolac 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 QLnabumetone RELAFEN generic 1naproxen NAPROSYN generic 1

naproxen delayed release ENTERIC COATED-NAPROSYN generic 1

oxaprozin DAYPRO generic 1piroxicam FELDENE generic 1salsalate DISALCID generic 1 QLsulindac CLINORIL generic 1

37

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Goutallopurinol ZYLOPRIM generic 1colchicine MITIGARE brand 2colchicine w/ probenecid COLBENEMID generic 1febuxostat ULORIC brand 2 STprobenecid PROBENECID generic 1Skeletal Muscle RelaxantsMuscle Spasmchlorzoxazone PARAFON FORTE DSC generic 1cyclobenzaprine FLEXERIL generic 1 5mg, 10mg, QLmethocarbamol ROBAXIN generic 1orphenadrine

extended-release NORFLEX generic 1

Spasticitybaclofen BACLOFEN generic 1dantrolene DANTRIUM generic 1diazepam VALIUM generic 1 QLtizanidine ZANAFLEX generic 1 tabs only, QL

OB-GYN

ContraceptivesBiphasicdesogestrel/EE MIRCETTE generic 1 QLnorethindrone/EE ORTHO-NOVUM 10/11 generic 1 QLEmergency Contraceptionlevonorgestrel PLAN B ONE STEP generic 1Extended Cyclelevonorgestrel/EE SEASONALE generic 1 QLInjectablemedroxyprogesterone

acetate DEPO-PROVERA generic 1 QL

Intravaginaletonogestrel/EE NUVARING brand 2 ring, QL

ortho diaphragmORTHO COILORTHO FLATORTHO FLEX

brand 2 QL

Monophasic - 20 mcg Estrogenlevonorgestrel/EE ALESSE generic 1 0.1/20, QLnorethindrone acetate/EE LOESTRIN 1/20 generic 1 1/20, QL

38

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

norethindrone acetate/EE/iron LOESTRIN FE 1/20 generic 1 1/20, QL

Monophasic - 30 mcg Estrogendesogestrel/EE ORTHO-CEPT generic 1 0.15/30, QLlevonorgestrel/EE NORDETTE generic 1 0.15/30, QLnorethindrone acetate/EE LOESTRIN 1.5/30 generic 1 1.5/30, QLnorethindrone acetate/EE/

iron LOESTRIN FE 1.5/30 generic 1 1.5/30, QL

norgestrel/EE LO/OVRAL generic 1 0.3/30, QLMonophasic - 35 mcg Estrogenethynodiol diacetate/EE ZOVIA 1/35 generic 1 1/35, QLnorethindrone/EE BALZIVA generic 1 0.4/35, QLnorethindrone/EE MODICON generic 1 0.5/35, QLnorethindrone/EE ORTHO-NOVUM 1/35 generic 1 1/35, QLnorgestimate/EE ORTHO-CYCLEN generic 1 0.25/35, QLMonophasic - 50 mcg Estrogenethynodiol diacetate/EE ZOVIA 1/50 generic 1 1/50, QLnorethindrone/EE OVCON 50 generic 1 1/50, QLnorethindrone/ME ORTHO-NOVUM 1/50 generic 1 1/50, QLnorgestrel/EE OVRAL generic 1 0.5/50, QLProgestinnorethindrone ORTHO MICRONOR generic 1progesterone micronized

cap PROMETRIUM generic 1

Transdermal

norelgestromin/EEORTHO EVRAXULANE

generic 1

Triphasicdesogestrel/EE CYCLESSA generic 1levonorgestrel/EE TRIVORA generic 1 QLnorethindrone/EE ORTHO-NOVUM 7/7/7 generic 1 QLnorethindrone/EE TRI-NORINYL generic 1 QLnorgestimate/EE ORTHO TRI-CYCLEN generic 1 QLEndometriosisdanazol DANOCRINE generic 1Hormone Therapy/MenopauseEstrogens - Injectableestradiol cypionate DEPO-ESTRADIOL brand 2

39

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Estrogens - Intravaginalestradiol ESTRACE CRM brand 2

estradiol vaginal tabletVAGIFEMYUVAFEM

generic 1 QL

estrogens, conjugated PREMARIN brand 2 crmEstrogens - Oralestradiol ESTRACE generic 1estrogens, conjugated PREMARIN brand 2estrogens, conjugated,

synthetic A CENESTIN brand 2

estropipate OGEN generic 1Estrogens - Transdermalestradiol CLIMARA generic 1 QLestradiol td ALORA brand 2 patchEstrogen/Progestinestrogens, conjugated/

medroxyprogesteronePREMPHASEPREMPRO

brand 2

Progestinsmedroxyprogesterone

acetate PROVERA generic 1

norethindrone acetate AYGESTIN generic 1progesterone inj PROGESTERONE INJ generic 1progesterone micronized PROMETRIUM generic 1Ovulation Stimulantschoriogonadotropin alfa OVIDREL brand 2 Diagnosis Requiredchorionic gonadotropin NOVAREL brand 2 Diagnosis RequiredVaginal InfectionsOralfluconazole DIFLUCAN generic 1 QLmetronidazole FLAGYL generic 1 tabsVaginalclotrimazole GYNE-LOTRIMIN generic 1 OTCclindamycin CLEOCIN brand 2 suppclindamycin CLEOCIN generic 1 crm

metronidazoleMETROGEL-VAGINAL METROGEL 1%

generic 1

miconazole MONISTAT generic 1 OTCmiconazole MONISTAT 3 generic 1terconazole TERAZOL 3/7 generic 1

40

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Miscellaneousconjugated estrogen/

bazedoxifene DUAVEE brand 2

methylergonovine METHERGINE generic 1tranexamic acid LYSTEDA generic 1 PA

Ophthalmic

Allergyazelastine OPTIVAR generic 1 STcromolyn sodium CROLOM generic 1 QLketotifen ALAWAY OTC generic 1

naphazoline/glycerin CLEAR EYES REDNESS RELIEF generic 1

naphazoline HCL VASOCLEAR generic 1 soln 0.02%naphazoline/zinc sulfate VASOCLEAR A brand 2 OTCtetrahydrozoline/

zinc sulfate VISINE-AC generic 1

Anti-InflammatoriesAnti-Infective/Anti-Inflammatory Combinationsbacitracin/polymyxin/

neomycin/hc CORTISPORIN generic 1 ointment

gentamicin/prednisolone acetate PRED-G brand 2

neomycin/polymyxin B/dexamethasone MAXITROL generic 1

neomycin/polymyxin B/hydrocortisone CORTISPORIN generic 1 suspension

sulfacetamide/pred phos VASOCIDIN generic 1 10%/0.25%tobramycin/

dexamethasone TOBRADEX generic 1

Nonsteroidaldiclofenac sodium VOLTAREN generic 1flurbiprofen OCUFEN generic 1ketorolac ACULAR/ACULAR LS genericSteroidaldexamethasone sodium

phosphate DEXASOL generic 1 soln 0.1%

fluorometholone FML brand 2 oint 0.1%

41

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

fluorometholone FML FORTE brand 2 susp 0.25%fluorometholone FML LIQUIFILM generic 1 susp 0.1%prednisolone acetate PRED FORTE generic 1 1%prednisolone acetate PRED MILD brand 2 0.12%prednisolone phosphate INFLAMASE FORTE generic 1 1%rimexolone VEXOL brand 2GlaucomaBeta-Blockerscarteolol generic 1 0.3% ophthalmic solutionlevobunolol BETAGAN generic 1 ophthalmic solutionmetipranolol OPTIPRANOLOL generic 1 0.3% ophthalmic solutiontimolol TIMOPTIC XE generic 1 gel forming solutiontimolol maleate TIMOPTIC generic 1Carbonic Anhydrase Inhibitorsdorzolamide TRUSOPT generic 1Carbonic Anhydrase Inhibitor/Beta-Blocker Combinationdorzolamide/

timolol maleate COSOPT generic 1

Cholinesterase Inhibitorecothiophate PHOSPHOLINE IODINE brand 2Mydriaticsatropine ISOPTO ATROPINE generic 1cyclopentolate CYCLOGYL generic 1 1%homatropine ISOPTO HOMATROPINE generic 1 5%homatropine ISOPTO HOMATROPINE brand 2 2%scopolamine ISOPTO HYOSCINE brand 2Oralacetazolamide ACETAZOLAMIDE generic 1acetazolamide

extended-release DIAMOX SEQUELS generic 1

methazolamide NEPTAZANE generic 1Prostaglandinslatanoprost XALATAN generic 1 QLTopical - Parasympathomimeticspilocarpine PILOPINE HS GEL brand 2pilocarpine ISOPTO CARPINE generic 1Topical - Sympathomimeticsbrimonidine ALPHAGAN P generic 1 0.15%brimonidine ALPHAGAN generic 1 0.2%

42

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Immunologic Agentslifitegrast XIIDRA brand 2 PAInfectionsBacterialbacitracin generic 1ciprofloxacin CILOXAN generic 1 solutionciprofloxacin CILOXAN brand 2 ointmenterythromycin ERYTHROMYCIN generic 1gatifloxin ZYMAR brand 2 PAgentamicin GENTAK generic 1neomycin/bacitracin/

polymyxin NEOSPORIN generic 1 ointment

neomycin/polymyxin B/gramicidin NEOSPORIN generic 1 solution

ofloxacin OCUFLOX generic 1polymyxin B/bacitracin POLYSPORIN generic 1polymyxin B/trimethoprim POLYTRIM generic 1sulfacetamide BLEPH-10 generic 1 oint/solntobramycin TOBREX generic 1Viral trifluridine VIROPTIC generic 1Miscellaneouscysteamine 0.44%

ophthalmic solution CYSTARAN brand 2 Diagnosis Required, SP

sodium chloride hypertonic MURO 128 generic 1 soln 5%

sodium chloride hypertonic ophth soln ALTACHLORE generic 1 OTC

tetracaine hcl ophth soln ALTACAINE generic 1

Psychiatric

Alcohol Deterrentsacamprosate CAMPRAL brand 2disulfiram ANTABUSE generic 1naltrexone REVIA generic 1AnxietyBenzodiazepinesalprazolam XANAX generic 1 QL, IR onlychlordiazepoxide LIBRIUM generic 1

43

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

clonazepam KLONOPIN generic 1 not wafersclorazepate TRANXENE generic 1diazepam VALIUM generic 1 QLlorazepam ATIVAN generic 1 QLoxazepam SERAX generic 1 QLMiscellaneousbuspirone BUSPAR generic 1clomipramine ANAFRANIL generic 1fluvoxamine LUVOX generic 1Attention Deficit Hyperactivity Disorder (ADHD) – Diagnosis Requiredamphetamine/

dextroamphetamine mixed salts

ADDERALL generic 1 Age Limits Apply, QL

amphetamine/ dextroamphetamine mixed salts extended-release

ADDERALL XR (BRAND ADDERALL XR IS PREFERRED)

brand 2 Age Limits Apply, QL

dexmethylphenidate FOCALIN generic 1 Age Limits Apply, QLguanfacine ER INTUNIV generic 1lisdexamfetamine VYVANSE brand 2 Age Limits Apply, QLlisdexamfetamine

chewable tab VYVANSE CHEWABLE brand 2 QL

methylphenidate RITALIN generic 1 Age Limits Apply, tabs only, QL

methylphenidate extended-release METADATE ER generic 1 Age Limits Apply, QL

methylphenidate extended-release RITALIN LA generic 1 Age Limits Apply, QL,

20 mg, 30 mg, 40 mg caps

methylphenidate HCL ER 24hr generic 1

Age Limits Apply, QL, 18 mg, 27 mg, 36 mg,

54 mg tablets, Mallinckrodt and Kremers

Urban labelersBipolar Disorderdivalproex sodium

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

authorization.divalproex sodium

delayed-release DEPAKOTE generic 1 Minimum age 2

lithium carbonate LITHIUM CARBONATE generic 1lithium carbonate

extended-releaseESKALITH CR LITHOBID

generic 1

44

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Depression*Monoamine Oxidase Inhibitor (MAOI)tranylcypromine PARNATE generic 1Selective Serotonin Reuptake Inhibitor (SSRIs)citalopram CELEXA generic 1 QLescitalopram LEXAPRO generic 1 tablets, QL

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

paroxetine PAXIL generic 1 QLsertraline ZOLOFT generic 1 tablets, QLSerotonin Norepinephrine Reuptake Inhibitors (SNRIs)duloxetine CYMBALTA generic 1 QLvenlafaxine EFFEXOR generic 1 QLvenlafaxine XR EFFEXOR XR generic 1 QLTricyclic Antidepressants (TCAs)amitriptyline ELAVIL generic 1 tabletsamoxapine generic 1desipramine NORPRAMIN generic 1doxepin SINEQUAN generic 1imipramine HCL TOFRANIL generic 1 tabletsnortriptyline PAMELOR generic 1Tricyclic Antidepressant/Phenothiazine Combinationamitriptyline/perphenazine TRIAVIL generic 1Miscellaneous Agentsbupropion WELLBUTRIN generic 1bupropion

extended-release WELLBUTRIN SR generic 1 QL

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

chlordiazepoxide- amitriptyline LIMBITROL generic 1

maprotiline LUDIOMIL generic 1mirtazapine REMERON generic 1 tabs (not soltabs)nefazodone hcl SERZONE generic 1

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

45

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

InsomniaBenzodiazepinesestazolam PROSOM generic 1flurazepam DALMANE generic 1 QLtemazepam RESTORIL generic 1 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 QLMedications Coverable for Participating Behavioral Health Prescribers*apomorphine

hydrochloride inj APOKYN brand 2 SP

aripiprazole ODT ABILIFY DISCMELT brand 2 Age Limits Applyaripiprazole oral solution ABILIFY SOLUTION brand 2 Age Limits Applyasenapine maleate

sublingual SAPHRIS brand 2 Age Limits Apply, QL

brexpiprazole REXULTI brand 2 QLbupropion HCL tab SR

24HR FORFIVO XL brand 2

bupropion hydrobromide APLENZIN brand 2carbamazepine

(antipsychotic) cap SR 12HR

EQUETRO brand 2

chlorpromazine hcl inj THORAZINE INJ generic 1clozapine CLOZARIL generic 1 200 mg, Age Limits Applyclozapine ODT FAZACLO generic 1 Age Limits Applyclozapine susp VERSACLOZ brand 2

desvenlafaxine fumarate tab SR 24HR

DESVENLAFAXINE FUMARATE TAB SR 24HR

generic 1

desvenlafaxine succinate tab SR 24HR PRISTIQ generic 1

desvenlafaxine tab SR 24HR KHEDEZLA generic 1

46

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

duloxetine IRENKA generic 1escitalopram oxalate soln LEXAPRO SOLUTION generic 1escitalopram &

methylfolate-B12-B6-D cap thpk

PRAMLYTE brand 2

fluoxetine capsule PROZAC generic 1 40mgfluoxetine HCL cap

delayed release 90 mg PROZAC WEEKLY generic 1

fluvoxamine maleate cap SR 24HR LUVOX CR generic 1

fluoxetine tablet FLUOXETINE generic 1iloperidone FANAPT brand 2 Age Limits Apply, QLimipramine pamoate TOFRANIL-PM generic 1isocarboxazid MARPLAN brand 2levomilnacipran FETZIMA brand 2loxapine aerosol powder

breath activated ADASUVE brand 2

lurasidone LATUDA brand 2 Age Limits Apply, QLmetreleptin MYALEPT brand 2 SPmirtazapine ODT REMERON SOLTAB generic 1olanzapine for IM inj ZYPREXA generic 1 injectableolanzapine-fluoxetine SYMBYAX generic 1 Age Limits Applyolanzapine ODT ZYPREXA ZYDIS generic 1 Age Limits Applyolanzapine pamoate for

extended rel IM sus ZYPREXA RELPREVV brand 2 Diagnosis Required, QL

paliperidone tab SR 24HR INVEGA generic 1 Age Limits Applyparoxetine HCL tab SR

24HR PAXIL CR generic 1

paroxetine mesylate tab PEXEVA brand 2phenelzine NARDIL generic 1pimavanserin NUPLAZID brand 2protriptyline VIVACTIL generic 1quetiapine fumarate tab

SR 24HR SEROQUEL XR generic 1 Age Limits Apply

risperidone microspheres for inj RISPERDAL CONSTA brand 2 Age Limits Apply, QL

risperidone ODT RISPERDAL M-TAB generic 1 Age Limits Apply

47

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

selegiline td patch EMSAM brand 2tasimelteon HETLIOZ brand 2 SPtrazodone DESYREL generic 1 300mgtrimipramine SURMONTIL brand 2venlafaxine HCL tab SR

24HRVENLAFAXINE HCL TAB SR

24HR generic 1

vilazodone VIIBRYD brand 2vortioxetine TRINTELLIX brand 2 tabsNarcotic 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 1PsychosesAtypicals*

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

aripiprazole ER injection ABILIFY MAINTENA brand 2 Age Limit Applies, PA, QLaripiprazole lauroxil IM ER

susp ARISTADA brand 2 Diagnosis Required, PA, QL

clozapine CLOZARIL generic 125mg, 50mg, 100mg

only, Age Limit Applies, QL

dextromethorphan/ quinidine NUEDEXTA brand 2 Diagnosis Required

olanzapine ZYPREXA generic 1 Age Limit Applies, tablets, QL

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

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

risperidone RISPERDAL CONSTA brand 2 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, QL

48

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Smoking Cessationbupropion HCl ZYBAN brand 2nicotine NICODERM CQ generic 1 patches, QLnicotine inhaler system NICOTROL INHALER brand 2 PA, QLnicotine nasal spray NICOTROL NASAL SPRAY brand 2 PA, QLnicotine polacrilex gum NICORETTE OTC generic 1 QLnicotine polacrilex lozenge COMMITT OTC generic 1 QLvarenicline CHANTIX brand 2 QLMiscellaneouschlorpromazine THORAZINE generic 1fluphenazine PROLIXIN generic 1fluphenazine decanoate PROLIXIN DECANOATE generic 1haloperidol HALDOL generic 1haloperidol decanoate HALDOL DECANOATE generic 1loxapine LOXITANE generic 1perphenazine TRILAFON generic 1pimozide ORAP generic 1thioridazine MELLARIL generic 1thiothixene NAVANE generic 1trifluoperazine STELAZINE generic 1

Respiratory DrugsAntitussives, Decongestants, Expectorants and Combinationsbenzonatate TESSALON generic 1brompheniramine &

phenylephrineDIMETAPP CLD ELX/

ALLERGY generic 1

brompheniramine/ pseudoephedrine

ACCUHIST DROPS UNI-HIST DROPS

generic 1

brompheniramine/ pseudoephedrine/ dextromethorphan

BROMFED DM generic 1 syrup

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

chlorphen tan/pyrilamine tan/PE tan

TRIOTANN PEDIATRIC SUSP

R-TANNAMINEgeneric 1 susp

49

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

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 LOHIST-D generic 1

chlorpheniramine tan/ phenylephrine tan RYNATAN PEDIATRIC SUSP generic 1 susp

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

codeine/promethazine PROMETHAZINE W/CODEINE generic 1 QL

codeine/promethazine/phenylephrine

PROMETHAZINE VC W/CODEINE generic 1 QL

dextromethorphan/ brompheniramine/pseudoephedrine

BROMETANE DX generic 1

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

dextromethorphan/ guaifenesin

GG/DM CRMUCINEX DMROBITUSSIN DMTUSSIN DM

generic 1 OTC

50

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

dextromethorphan- guaifenesin

ROBITUSSIN LIQ CGH/CONG generic 1 liq 10-200 mg/ 5 ml

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 extended-release MUCINEX generic 1 OTC

guaifenesin/ pseudoephedrine

ROBITUSSIN PE PSE/GG

generic 1 syrup, OTC

guaifenesin/ pseudoephedrine/ dextromethorphan

ROBITUSSIN CF generic 1

guaifenesin/ pseudoephedrine extended-release

MUCINEX D generic 1 OTC

hydrocodone/ homatropine

HYCODANHYDROMET SYPHYDROCODONE/

TAB HOMATROP

generic 1

loratadine & pseudoephedrine SR 24hr

CLARITIN-D generic 1

phenylephrine/ brompheniramine/ dextromethorphan

generic 1 OTC

phenylephrine/ chlorpheniramine/ dextromethorphan

RONDEC DMSTATUSS DM SYPCARDEC DM SYPMINUTUSS DR SYP

generic 1 syrup

51

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

phenylephrine/ chlorpheniramine/ dextromethorphan

RONDEC DM DROPSCARDEC DM DROROBITUSSIN LIQ

CGH/ALRG

generic 1 liquid

phenylephrine/ chlorpheniramine/ dihydrocodeine

DIHYDRO-PE SYP generic 1

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

potassium iodide SSKI brand 2 solnpromethazine &

phenylephrinePROMETH VC SYP

6.25-5/5 generic 1 syrup 6.25-5 mg/ 5 mg

pseudoephedrine/ acetaminophen/ dextromethorphan

MAPAP COLD TAB generic 1

pseudoephedrine/ chlorpheniramine/ dextromethorphan

PEDIACARE LIQ MULTI-SY

ROBITUSSIN LIQ PED NGHT

generic 1

pseudoephedrine/ dextromethorphan/guaifenesin

MULTI SYMPTOM TAB COLD RLF generic 1

pseudoephedrine/ iburprofen

CHILD IBUPRO SUS COLD

IBUOROFEN TAB COLD/SIN

generic 1

52

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

pseudoephedrine tan/ dexchlorphen tan/ DM tan

TANAFED DMX SUSPENSION

TRI-FED Xgeneric 1 susp

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 QL

mometasone inhalation ASMANEX HFA brand 2Patients 8 years and

older will require prior authorization, QL

Inhalers - Corticosteroid/Beta Agonist Combinationsfluticasone/salmeterol AIRDUO RESPICLICK generic 1 QLfluticasone/vilanterol BREO ELLIPTA brand 2 STInhalers - Othersipratropium/albuterol COMBIVENT brand 2 QLipratropium/albuterol COMBIVENT RESPIMAT brand 2 inhaleripratropium HFA ATROVENT HFA brand 2omalizumab XOLAIR brand 2 PA, SPtiotropium/olodaterol STIOLTO RESPIMAT brand 2umeclidinium 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%albuterol sulfate ACCUNEB generic 1 soln nebu

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

authorization. QL

53

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

cromolyn 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 VOSPIRE ER generic 1 tabmetaproterenol METAPROTERENOL SYRUP generic 1terbutaline BRETHINE generic 1Oral Agents - Leukotriene Modifiersmontelukast SINGULAIR generic 1 QLOral Agents - Theophyllinetheophylline THEOPHYLLINE generic 1 liquidtheophylline

extended-release THEO-24 brand 2 caps

theophylline extended-release

THEOCHRONUNIPHYL

generic 1 tabs

Urological

Symptomatic Benign Prostatic Hypertrophyalfuzosin ER UROXATRAL generic 1doxazosin CARDURA generic 1finasteride PROSCAR generic 1tamsulosin FLOMAX generic 1terazosin HYTRIN generic 1Miscellaneousbethanechol URECHOLINE generic 1flavoxate hcl FLAVOXATE generic 1hyoscyamine,

methenamine, phenyl salicylate, sodium phosphate monobasic, methylene blue

UTIRA C brand 2

methenamine hippurateHIPREXUREX

generic 1

oxybutynin chloride DITROPAN XL generic 1 QLoxybutynin IR DITROPAN generic 1

54

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

oxybutynin patch OXYTROL FOR WOMEN OTC PATCH brand 2

pentosan polysulfate sodium ELMIRON brand 2 Diagnosis Required

phenazopyridine PYRIDIUM generic 1potassium citrate UROCIT-K generic 1propantheline generic 1sodium citrate/citric acid BICITRA generic 1tolterodine DETROL generic 1 STtrospium SANCTURA generic 1 ST

Vitamins and Mineralsb-complex w/c & e VI-STRESS generic 1 tab, OTCb-complex w/c & e + zn BEC/ZINC generic 1 tab, OTCb-complex w/ c &

folic acid EQL B COMPLEX generic 1 tab, OTC

b-complex w/minerals GERAVIM generic 1 liq, OTCcalcitriol ROCALTROL generic 1

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

authorization.calcium OS-CAL generic 1 OTCcyanocobalamin VITAMIN B-12 generic 1 injelectrolyte PEDIALYTE generic 1 soln, oral, OTCergocalciferol (D2) DRISDOL generic 1ferrous bisglycinate/

polysaccarides iron NIFEREX generic 1 caps, OTC

ferrous sulfate FEOSOL generic 1 OTC

fluoride

GEL-KAMLURIDE LURIDE LOZI-TABSPREVIDENTPHOS-FLUR

generic 1

folic acid FOLIC ACID generic 1folic acid-vitamin

b6-vitamin b12 FABB brand 2 tab 2.2-25-1 mg, PA

magnesium chloride MAG64 generic 1 OTCmagnesium oxide MAG-OX generic 1 OTCmultiple vitamin THERA-PLUS generic 1 liquid, OTC

55

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

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

multivitamins/minerals CENTRUM generic 1 OTCphytonadione MEPHYTON brand 2polysaccharide iron

complex NIFEREX generic 1 elixir, OTC

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

COMPLETE NATALCARE PAK DHA brand 2

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

TRUST NATALCARE PAK DHA brand 2

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

PRUET DHA PAK SETONET PAK brand 2

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

PRUET DHAEC PAK brand 2

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

FOLTABS PAK PLUS DHA RE OB + DHA PAK brand 2

prenatal vit w/FE bisglycinate chelate-FA

VINATE II brand 2

prenatal vit w/FE bisglycinate chelate-FA

GENTEX ADE 28-1 MG brand 2

prenatal vit w/FE bisglycinate chelate-FA

VINATE AZ EX brand 2

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

prenatal vit w/iron carbonyl-FA ATABEX PRENATAL brand 2

56

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

prenatal vitamins w/folic acid

PRENATAL VITAMINS W/ FOLIC ACID

CENOGEN OB/ULTRAMATERNANATALCARENESTABSCBF/FA/RXNIFEREX-PN FORTE

generic 1 QL

prenatal w/o A w/FE carbonyl-FE gluc-DSS-FA

FOLTABS PRENATALTRI RX

brand 2

vitamin A generic 1 OTCvitamin ADC/fluoride/±iron

drops TRI-VI-FLOR generic 1

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

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

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

zinc generic 1 OTCzinc sulfate ZINCATE generic 1 OTC, 220 mgPotassiumphosphorus K-PHOS NEUTRAL generic 1 tabspotassium acid phosphate K-PHOS ORIGINAL brand 2potassium bicarbonate/

potassium citrate effervescent

K-LYTE generic 1 tabs

potassium chloride ext-rel MICRO-K 10 generic 1 caps

potassium chloride extended-release

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

generic 1 tabs

potassium chloride POTASSIUM CHLORIDE generic 1 liquidpotassium chloride K-LOR generic 1 powder

57

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Miscellaneous

Anaphylaxis

epinephrineEPIPEN EPIPEN JR.

generic 1 QL

Antidotesacetylcysteine CETYLEV brand 2succimer CHEMET brand 2 QLCystic 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, SPHereditary Angioedemac1 esterase inhibitor

(human) BERINERT brand 2 PA, SP

c1 esterase inhibitor (human) HAEGARDA brand 2 PA, QL, SP

icatibant FIRAZYR brand 2 PA, SPHyperphosphatemiacalcium acetate generic 1 667 mg tablet onlycinacalcet 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, SPMedical Devicesinsulin syringes QLlancets QLspacers QL

58

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

Metabolic Modifierscarglumic acid CARBAGLU brand 2 PA, SPglycerol phenylbutyrate RAVICTI brand 2 PA, SPsodium phenylbutyrate BUPHENYL generic 1 Diagnosis Required, SPVaccinediphtheria-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 QUAD FLUZONE 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

59

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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

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

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

ADACELBOOSTRIX

brand 2 QL

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

tetanus-diphtheria toxoids (td)

TENIVACTET/DIP TOX INJ

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 ApplyMiscellaneoussodium chloride irrigation

soln 0.9% generic 1

60

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

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 drug

list. OTC products covered are restricted to generics when available. Brand names are provided

as reference only.Acneadapalene gel DIFFERIN OTC GEL 0.1%benzoyl peroxide crm, gel, lotion CLEARASILsalicylic acid lotion 2% SALACAntifungalsclotrimazole

miconazole crm

tolnaftate

MICATINLOTRIMIN AFTINACTIN

vaginal productsMONISTATGYNE-LOTRIMIN

Antiviralsdocosanol ABREVA OTC CREAMAtopic Dermatitisdimethicone lotion 3% ALOE VESTA

emollients

BETACARE CREAM AND LOTIONCETAPHIL CREAM AND LOTIONDERMAPHOR OINTMENTE-OINTMENTGLYCERIN TOPICAL

Cough/Cold Allergy

antihistamines

CHLOR-TRIMETONBENADRYLCLARITINALAVERTZYRTEC

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

61

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

Generic Drug Name Brand Drug Name Examples

loratadine/pseudoephedrineALAVERT ALRG TAB/SINUSALAVERT D ALLERGY/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 gel 40% GLUTOSE 15glucose oral tablets

insulin (vials only) HUMULINNOVOLIN

Earwax Removal Productscarbamide peroxide DEBROXFamily Planning

condom-male

TROJAN KIMONOLIFESTYLESTRUSTEXDUREXFANTASY

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

topical antibacterialsNEOSPORINBACITRACIN

62

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

Generic Drug Name Brand Drug Name Examples

Gastrointestinalaluminum hydroxide gel susp (320 mg/5 ml only) ALUMINUM HYDROXIDE

antacids liquids, chew tabsMYLANTA LIQUIDMAALOX LIQUIDTUMS

antidiarrhealsIMODIUM A-DKAOPECTATE

electrolyte rehydrating soln PEDIALYTEfamotidine PEPCID AClaxative enemas FLEET ENEMA

laxativesDULCOLAXFLEET PHOSPHO-SODA

magnesium hydroxide susp MILK OF MAGNESIA

probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

psylliumMETAMUCILKONSYL-D

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

63

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

ST = Step TherapySP = Specialty Pharmacy

*Available without PA for participating Behavioral Health Prescribers

Generic Drug Name Brand Drug Name Examples

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

nicotineCOMMIT LOZENGES (QUANTITY LIMIT)NICODERM CQ (QUANTITY LIMIT)NICOTINE GUM (QUANTITY LIMIT)

Urologicaloxybutynin patch OXYTROL FOR WOMEN OTC PATCHVitamins/Minerals

calciumOS-CALCALTRATETUMS

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

FERGONFEOSOL

iron polysaccharides NIFEREXmagnesium 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

64

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

Index of Covered Drugs

Aabacavir . . . . . . . . . . . . . . .33, 34abacavir/dolutegravir/

lamivudine . . . . . . . . . . . . . 34abacavir/lamivudine . . . . . . . . 33abacavir/lamivudine/

zidovudine . . . . . . . . . . . . . 33abaloparatide inj . . . . . . . . . . . 26abemaciclib . . . . . . . . . . . . . . . . 4ABILIFY DISCMELT . . . . . . . . 45ABILIFY MAINTENA . . . . . . . . 47ABILIFY SOLUTION . . . . . . . . 45ABILIFY TABLETS . . . . . . . . . 47abiraterone . . . . . . . . . . . . . . . . . 5ABREVA OTC CREAM . . .33, 60ABSORICA . . . . . . . . . . . . . . . 18acalabrutinib . . . . . . . . . . . . . . . 4acamprosate . . . . . . . . . . . . . . 42acarbose . . . . . . . . . . . . . . . . . 25ACCUHIST DROPS . . . . . . . . 48ACCUNEB . . . . . . . . . . . . . . . . 52ACCUPRIL . . . . . . . . . . . . . . . . . 8ACCURETIC . . . . . . . . . . . . . . . 9acebutolol . . . . . . . . . . . . . . . . . 9ACEON . . . . . . . . . . . . . . . . . . . . 8acetaminophen

. . . . . . . . . 13-15, 36, 51, 63acetaminophen tabs, liquid,

drops, suppositories, chew tabs . . . . . . . . . . . . . . . . . . . 63

acetazolamide . . . . . . . . . . . . . 41acetazolamide

extended-release . . . . . . . 41acetic acid . . . . . . . . . . . . . . . . 22acetic acid/aluminum

acetate . . . . . . . . . . . . . . . . 22acetic acid/hydrocortisone . . 22acetylcysteine . . . . . . . . . . . . . 57acidophilus . . . . . . . . . . . . . . . 29ACIDOPHILUS XTRA . . . . . . . 29acidophilus/bifidus . . . . . . . . . 29ACIDOPHILUS/BIFIDUS

WAFER . . . . . . . . . . . . . . . . 29acidophilus/citrus pectin . . . . 29acidophilus/pectin . . . . . . . . . 29acitretin . . . . . . . . . . . . . . . . . . . 20

ACLOVATE . . . . . . . . . . . . . . . . 19ACTIFED . . . . . . . . . . . . . .23, 60ACTIGALL . . . . . . . . . . . . . . . . 30ACTIMMUNE . . . . . . . . . . . . . . . 6ACTOS . . . . . . . . . . . . . . . . . . . 25ACULAR/ACULAR LS . . . . . . 40acyclovir . . . . . . . . . . . . . . . . . . 33ADACEL . . . . . . . . . . . . . . . . . . 59ADALAT CC . . . . . . . . . . . . . . . 10adalimumab . . . . . . . . . . . . . . . 35adapalene gel . . . . . . . . . .18, 60ADASUVE . . . . . . . . . . . . . . . . 46ADDERALL . . . . . . . . . . . . . . . 43ADDERALL XR . . . . . . . . . . . . 43ADEMPAS . . . . . . . . . . . . . . . . 12ADLYXIN . . . . . . . . . . . . . . . . . 26ADMELOG SOLOSTAR . . . . . 25ADMELOG VIALS . . . . . . . . . . 25ADVIL . . . . . . . . . . . . . 14, 36, 63afatinib . . . . . . . . . . . . . . . . . . . . 4AFINITOR . . . . . . . . . . . . . . . . . . 5AFINITOR DISPERZ . . . . . . . . . 5AFLURIA . . . . . . . . . . . . . . . . . 58AFLURIA PF . . . . . . . . . . . . . . . 58AFRIN . . . . . . . . . . . . . . . . .23, 61AGRYLIN . . . . . . . . . . . . . . . . . . 7AIRDUO RESPICLICK . . . . . . 52ALAVERT . . . . . . . 22, 23, 60, 61ALAVERT ALRG TAB/

SINUS . . . . . . . . . . . . . .23, 61ALAVERT D . . . . . . . . . . . . . . . 61ALAVERT-D . . . . . . . . . . . . . . . 23ALAWAY . . . . . . . . . . . . . . .40, 63ALAWAY OTC . . . . . . . . . . . . . 40albendazole . . . . . . . . . . . . . . . 30ALBENZA . . . . . . . . . . . . . . . . 30albiglutide . . . . . . . . . . . . . . . . 26albuterol . . . . . . . . . . . . . . .52, 53albuterol sulfate . . . . . . . . .52, 53alclometasone . . . . . . . . . . . . . 19alcohol swabs . . . . . . . . . . . . . 61ALDACTAZIDE . . . . . . . . . . . . 11ALDACTONE . . . . . . . . . . . . . . 11ALDARA . . . . . . . . . . . . . . . . . . 21ALDOMET . . . . . . . . . . . . . . . . 12ALDORIL . . . . . . . . . . . . . . . . . 12

ALECENSA . . . . . . . . . . . . . . . . 4alectinib . . . . . . . . . . . . . . . . . . . 4alendronate . . . . . . . . . . . . . . . 26ALESSE . . . . . . . . . . . . . . . . . . 37alfuzosin ER . . . . . . . . . . . . . . . 53alginic acid/sodium

bicarbonate . . . . . . . . . . . . 28ALIGN . . . . . . . . . . . . . . . . .29, 62ALINIA . . . . . . . . . . . . . . . . . . . 32ALINIA SUSPENSION . . . . . . 32alirocumab . . . . . . . . . . . . . . . . 11alitretinoin 1% gel . . . . . . . . . . . 6ALKERAN . . . . . . . . . . . . . . . . . 4allergic conjunctivitis . . . . . . . 63ALLERGY/CONG . . . . . . .23, 61allopurinol . . . . . . . . . . . . . . . . 37ALOE VESTA . . . . . . . . . . . . . . 60alogliptin . . . . . . . . . . . . . . . . . . 25alogliptin/metformin . . . . . . . . 25alogliptin/pioglitazone . . . . . . 25ALORA . . . . . . . . . . . . . . . . . . . 39ALPHAGAN . . . . . . . . . . . . . . . 41ALPHAGAN P . . . . . . . . . . . . . 41alprazolam . . . . . . . . . . . . . . . . 42ALTACAINE . . . . . . . . . . . . . . . 42ALTACE . . . . . . . . . . . . . . . . . . . 8ALTACHLORE . . . . . . . . . . . . . 42altretamine . . . . . . . . . . . . . . . . . 4alumina/magnesia . . . . . . . . . 28alumina/magnesia/

simethicone . . . . . . . . . . . . 28aluminum acetate . . . . . . .20, 22aluminum chloride topical

solution . . . . . . . . . . . . . . . 20ALUMINUM HYDROXIDE . . . 62aluminum hydroxide gel susp

(320 mg/5 ml only) . . . . . 62alunbrig . . . . . . . . . . . . . . . . . . . 4amantadine . . . . . . . . . . . .16, 33AMARYL . . . . . . . . . . . . . . . . . 25AMBIEN . . . . . . . . . . . . . . . . . . 45ambrisentan . . . . . . . . . . . . . . . 12AMERGE . . . . . . . . . . . . . . . . . 15AMICAR . . . . . . . . . . . . . . . . . . . 8amiloride . . . . . . . . . . . . . . . . . 10

65

Index of Covered Drugs

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

amiloride/ hydrochlorothiazide . . . . . 10

aminocaproic acid . . . . . . . . . . 8aminosalicyclic acid . . . . . . . . 30amiodarone tabs . . . . . . . . . . . . 9amitriptyline . . . . . . . . . . . .15, 44amitriptyline/perphenazine . . 44amlodipine . . . . . . . . . . . . . . . . 10amlodipine-benazepril . . . . . . 10ammonium lactate . . . . . . . . . 21AMNESTEEM . . . . . . . . . . . . . 18amoxapine . . . . . . . . . . . . . . . . 44amoxicillin . . . . . . . . . . . . . . . . 31AMOXICILLIN CAPSULES AND

CHEWABLES . . . . . . . . . . 31amoxicillin/clavulanate . . . . . . 31AMOXIL SUSP. . . . . . . . . . . . . 31amphetamine/

dextroamphetamine mixed salts . . . . . . . . . . . . . . . . . . 43

amphetamine/dextroamphetamine mixed salts extended-release . . . 43

ampicillin . . . . . . . . . . . . . . . . . 31ANAFRANIL . . . . . . . . . . . . . . . 43anagrelide . . . . . . . . . . . . . . . . . 7anakinra . . . . . . . . . . . . . . . . . . 35anastrozole. . . . . . . . . . . . . . . . . 5ANTABUSE . . . . . . . . . . . . . . . 42antacids liquids, chew tabs . . 62antidiarrheals . . . . . . . . . . . . . . 62antihistamines . . . . . . . . . .22, 60antitussives . . . . . . . . . 3, 48, 61ANTIVERT . . . . . . . . . . . . . . . . 27ANUSOL HC 2.5% . . . . . . . . . 21APHEDRID TAB . . . . . . . . . . . 52apixaban . . . . . . . . . . . . . . . . . . 7APLENZIN . . . . . . . . . . . . . . . . 45APOKYN . . . . . . . . . . . . . . . . . 45apomorphine hydrochloride

inj . . . . . . . . . . . . . . . . . . . . 45apremilast . . . . . . . . . . . . . . . . 35aprepitant . . . . . . . . . . . . . . . . . 27APRESOLINE . . . . . . . . . . . . . 12APRISO . . . . . . . . . . . . . . . . . . 29APTIVUS . . . . . . . . . . . . . . . . . 34

ARALEN . . . . . . . . . . . . . . . . . . 35ARANESP . . . . . . . . . . . . . . . . . 7ARAVA . . . . . . . . . . . . . . . . . . . 35ARCAPTA NEOHALER . . . . . 52ARICEPT . . . . . . . . . . . . . . . . . 13ARIMIDEX . . . . . . . . . . . . . . . . . 5aripiprazole . . . . . . . . . . . .45, 47aripiprazole ER injection . . . . 47aripiprazole lauroxil IM

ER susp . . . . . . . . . . . . . . . 47aripiprazole ODT . . . . . . . . . . . 45aripiprazole oral solution . . . . 45ARISTADA . . . . . . . . . . . . . . . . 47armodafinil . . . . . . . . . . . . . . . . 13ARNUITY ELLIPTA . . . . . . . . . 52AROMASIN . . . . . . . . . . . . . . . . 5ARTANE . . . . . . . . . . . . . . . . . . 16artificial tears . . . . . . . . . . . . . . 63asenapine maleate

sublingual . . . . . . . . . . . . . 45asfotase alfa . . . . . . . . . . . . . . . 26ASMANEX HFA . . . . . . . . . . . . 52aspirin . . . . . . . .7, 13, 15, 36, 63aspirin tabs, EC tabs,

chew tabs . . . . . . . . . . . . . 63aspirin with buffers tabs . . . . . 63aspirin/acetaminophen/

caffeine . . . . . . . . . . . . . . . 13ASTELIN. . . . . . . . . . . . . . . . . . 22ATABEX PRENATAL . . . . . . . . 55ATARAX . . . . . . . . . . . . . . . . . . 22atazanavir . . . . . . . . . . . . . . . . . 34atenolol . . . . . . . . . . . . . . . . . . . . 9atenolol/chlorthalidone . . . . . . 9ATIVAN . . . . . . . . . . . . . . . . . . . 43atorvastatin . . . . . . . . . . . . . . . 11atovaquone . . . . . . . . . . . . . . . 32ATRIPLA . . . . . . . . . . . . . . . . . . 33atropine . . . . . . . . . . . 27, 30, 41atropine sulfate . . . . . . . . . . . . 30ATROVENT . . . . . . . . 23, 52, 53ATROVENT HFA . . . . . . . . . . . 52ATROVENT NASAL SPRAY . 23AUBAGIO . . . . . . . . . . . . . . . . . 16AUGMENTIN . . . . . . . . . . . . . . 31auranofin . . . . . . . . . . . . . . . . . 35

AVITA . . . . . . . . . . . . . . . . . . . . 18axitinib . . . . . . . . . . . . . . . . . . . . 4AYGESTIN . . . . . . . . . . . . . . . . 39azathioprine . . . . . . . . . . . . . 6, 35azelaic acid . . . . . . . . . . . . . . . 18azelastine . . . . . . . . . . . . . .22, 40azithromycin . . . . . . . . . . . . . . 31aztreonam . . . . . . . . . . . . . . . . 57AZULFIDINE . . . . . . . . . . .29, 36AZULFIDINE EN-TABS . . .29, 36

Bb-complex w/ c & folic acid . . 54b-complex w/c & e . . . . . . . . . 54b-complex w/c & e + zn . . . . . 54b-complex w/minerals . . . . . . 54BACID . . . . . . . . . . . . . . . . .29, 62bacitracin . . . . . . . 18, 40, 42, 61bacitracin/polymyxin/

neomycin/hc . . . . . . . . . . . 40baclofen . . . . . . . . . . . . . . . . . . 37BACTRIM . . . . . . . . . . . . . . . . . 31BACTRIM DS . . . . . . . . . . . . . . 31BACTROBAN . . . . . . . . . . . . . 18balsalazide . . . . . . . . . . . . . . . . 29BALZIVA . . . . . . . . . . . . . . . . . . 38BANZEL . . . . . . . . . . . . . . . . . . 17BARACLUDE . . . . . . . . . . . . . . 32BASAGLAR . . . . . . . . . . . . . . . 24BAYER . . . . . . . . . . . . . 7, 36, 63BEC/ZINC . . . . . . . . . . . . . . . . 54becaplermin gel . . . . . . . . . . . 21beclomethasone . . . . . . . . . . . 52bedaquiline . . . . . . . . . . . . . . . 35BENADRYL . . . . . . . . . . . .22, 60BENADRYL-D . . . . . . . . . . . . . 23benazepril . . . . . . . . . . . . . . . . . 8benazepril/

hydrochlorothiazide . . . . . . 8BENTYL . . . . . . . . . . . . . . . . . . 28BENZAC AC . . . . . . . . . . . . . . 18BENZAMYCIN . . . . . . . . . . . . . 18benznidazole . . . . . . . . . . . . . . 32benzocaine/antipyrine . . . . . . 22benzonatate . . . . . . . . . . . . . . . 48BENZOTIC . . . . . . . . . . . . . . . . 22

66

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

Index of Covered Drugsbenzoyl peroxide . . . . . . . .18, 60benzoyl peroxide crm, gel,

lotion . . . . . . . . . . . . . . . . . . 60benztropine . . . . . . . . . . . . . . . 16BERINERT . . . . . . . . . . . . . . . . 57BETA-VAL . . . . . . . . . . . . . . . . 19BETACARE CREAM AND

LOTION . . . . . . . . . . . . . . . 60BETAGAN . . . . . . . . . . . . . . . . 41betamethasone augmented

dip . . . . . . . . . . . . . . . . . . . . 19betamethasone dip

augmented . . . . . . . . . . . . 19betamethasone dipropionate 19betamethasone val . . . . . . . . . 19BETAPACE . . . . . . . . . . . . . . . 10BETAPACE AF . . . . . . . . . . . . . 10betaxolol . . . . . . . . . . . . . . . . . . . 9bethanechol . . . . . . . . . . . . . . . 53BETHKIS . . . . . . . . . . . . . . . . . 57betrixaban . . . . . . . . . . . . . . . . . 7BEVYXXA . . . . . . . . . . . . . . . . . 7bexarotene caps and

topical gel . . . . . . . . . . . . . . 6BIAXIN . . . . . . . . . . . . . . . . . . . 31BIAXIN XL . . . . . . . . . . . . . . . . 31bicalutamide . . . . . . . . . . . . . . . 5BICITRA . . . . . . . . . . . . . . . . . . 54BILTRICIDE . . . . . . . . . . . . . . . 30BIOGAIA . . . . . . . . . . . . . . .29, 62bisoprolol . . . . . . . . . . . . . . . . . . 9bisoprolol/

hydrochlorothiazide . . . . . . 9BLEPH-10 . . . . . . . . . . . . . . . . 42BONINE . . . . . . . . . . . . . . . . . . 62BOOSTRIX . . . . . . . . . . . . . . . . 59bosentan . . . . . . . . . . . . . . . . . 12BOSULIF . . . . . . . . . . . . . . . . . . 4bosutinib . . . . . . . . . . . . . . . . . . 4BREO ELLIPTA . . . . . . . . . . . . 52BRETHINE . . . . . . . . . . . . . . . . 53brexpiprazole . . . . . . . . . . . . . . 45brigatinib . . . . . . . . . . . . . . . . . . 4BRILINTA . . . . . . . . . . . . . . . . . . 8brimonidine . . . . . . . . . . . .20, 41BROMETANE DX . . . . . . . . . . 49

BROMFED DM . . . . . . . . . . . . 48brompheniramine &

phenylephrine . . . . . . . . . . 48brompheniramine/

pseudoephedrine 48, 49, 60brompheniramine/

pseudoephedrine/dextromethorphan . . . . . . 48

budesonide . . . . . . . . . . . .29, 52bumetanide . . . . . . . . . . . . . . . 10BUMEX . . . . . . . . . . . . . . . . . . . 10BUPHENYL . . . . . . . . . . . . . . . 58buprenorphine . . . . . . . . . . . . 47buprenorphine/naloxone . . . . 47bupropion . . . . . . . . . 44, 45, 48bupropion extended-release . 44bupropion HCl . . . . . . . . . .45, 48bupropion HCL tab SR

24HR . . . . . . . . . . . . . . . . . 45bupropion hydrobromide . . . 45Burow’s soln, wet dressings . 61BUSPAR . . . . . . . . . . . . . . . . . . 43buspirone . . . . . . . . . . . . . . . . . 43busulfan . . . . . . . . . . . . . . . . . . . 4butalbital/acetaminophen . . . 13butalbital/acetaminophen/

caffeine . . . . . . . . . . . . . . . 13butalbital/apap/caff/cod . . . . 14butalbital/asa/caff/cod . . . . . 14butalbital/aspirin/caffeine . . . 13butorphanol . . . . . . . . . . . . . . . 14

Cc1 esterase inhibitor (human) 57cabergoline . . . . . . . . . . . . . . . 26CABOMETYX . . . . . . . . . . . . . . 4cabozantinib . . . . . . . . . . . . . . . 4CAFERGOT . . . . . . . . . . . . . . . 15calamine . . . . . . . . . . . . . . . . . . 21CALAN . . . . . . . . . . . . . . . .10, 15CALAN SR . . . . . . . . . . . . . . . . 10calcipotriene . . . . . . . . . . . . . . 20calcitonin-salmon . . . . . . . . . . 26calcitriol . . . . . . . . . . . . . . .20, 54calcitriol oral soln . . . . . . . . . . 54calcium . 2, 7, 10, 27, 54, 57, 63

calcium acetate . . . . . . . . . . . . 57CALQUENCE . . . . . . . . . . . . . . 4CALTRATE . . . . . . . . . . . . . . . . 63CAMPRAL . . . . . . . . . . . . . . . . 42canakinumab . . . . . . . . . . . . . 35CANASA. . . . . . . . . . . . . . . . . . 29capecitabine . . . . . . . . . . . . . . . 4CAPOTEN . . . . . . . . . . . . . . . . . 8CAPOZIDE . . . . . . . . . . . . . . . . . 8CAPRELSA . . . . . . . . . . . . . . . . 5CAPSAGEL . . . . . . . . . . . . . . . 36capsaicin . . . . . . . . . . . . . . . . . 36captopril . . . . . . . . . . . . . . . . . . . 8captopril/hydrochlorothiazide . 8CAPZASIN-P . . . . . . . . . . . . . . 36CARAFATE . . . . . . . . . . . . . . . . 28CARAFATE SUSPENSION . . 28CARBAGLU . . . . . . . . . . . . . . . 58carbamazepine . . . . . . . . .16, 45carbamazepine (antipsychotic)

cap SR 12HR . . . . . . . . . . 45carbamazepine extended-

release . . . . . . . . . . . . . . . . 16carbamide peroxide . . . . .22, 61CARBATROL . . . . . . . . . . . . . . 16carbidopa/levodopa . . . . . . . . 16carbidopa/levodopa

extended-release . . . . . . . 16CARDEC DM DRO . . . . . . . . . 51CARDEC DM SYP . . . . . . . . . 50CARDEC DRO . . . . . . . . . . . . . 49CARDEC SYP . . . . . . . . . . . . . 49CARDENE . . . . . . . . . . . . . . . . 10CARDIZEM . . . . . . . . . . . . . . . 10CARDIZEM CD . . . . . . . . . . . . 10CARDIZEM SR . . . . . . . . . . . . 10CARDURA . . . . . . . . . . . . . . 9, 53carglumic acid . . . . . . . . . . . . . 58carteolol . . . . . . . . . . . . . . . . . . 41carvedilol . . . . . . . . . . . . . . . . . . 9casanthranol-docusate

sodium . . . . . . . . . . . . . . . . 27CASODEX . . . . . . . . . . . . . . . . . 5CASTIVA . . . . . . . . . . . . . . . . . 36CATAFLAM . . . . . . . . . . . . . . . 13CATALFAM. . . . . . . . . . . . . . . . 36

67

Index of Covered Drugs

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

CATAPRES . . . . . . . . . . . . . . . . . 9CATAPRES- TTS . . . . . . . . . . . . 9CAYSTON . . . . . . . . . . . . . . . . 57CECLOR . . . . . . . . . . . . . . . . . 30cefaclor . . . . . . . . . . . . . . . . . . . 30cefadroxil . . . . . . . . . . . . . . . . . 30cefdinir . . . . . . . . . . . . . . . . . . . 31cefixime . . . . . . . . . . . . . . . . . . 31cefprozil . . . . . . . . . . . . . . . . . . 30CEFTIN . . . . . . . . . . . . . . . .30, 31cefuroxime axetil . . . . . . . .30, 31CEFZIL . . . . . . . . . . . . . . . . . . . 30CELEBREX . . . . . . . . . . . . . . . 36celecoxib . . . . . . . . . . . . . . . . . 36CELEXA . . . . . . . . . . . . . . . . . . 44CELLCEPT . . . . . . . . . . . . . . . . . 6CELONTIN . . . . . . . . . . . . . . . . 17CENESTIN . . . . . . . . . . . . . . . . 39CENOGEN OB/ULTRA . . . . . 56CENTRUM . . . . . . . . . . . . . . . . 55cephalexin . . . . . . . . . . . . . . . . 30ceritinib . . . . . . . . . . . . . . . . . . . . 4certolizumab pegol . . . . . . . . . 35CETAPHIL CREAM AND

LOTION . . . . . . . . . . . . . . . 60cetirizine . . . . . . . . . . . 22, 23, 60cetirizine chew tab . . . . . . . . . 22cetirizine hydrochloride/

pseudoephedrine hydrochloride 12 hours extended-release . . . . . . . 23

cetirizine/pseudoephedrine . 60CETYLEV . . . . . . . . . . . . . . . . . 57CHANTIX . . . . . . . . . . . . . . . . . 48CHEMET . . . . . . . . . . . . . . . . . 57CHILD IBUPRO SUS COLD . 51CHLOR-TRIMETON . . . . .22, 60CHLOR-TRIMETON

ALLERGY . . . . . . . . . . . . . 22CHLOR-TRIMETON SYRUP . 22chloral hydrate . . . . . . . . . . . . . 45chlorambucil . . . . . . . . . . . . . . . 4chlordiazepoxide. . . . . . . . . . . 42

chlordiazepoxide- amitriptyline . . . . . . . . . . . 44

chlorhexidine gluconate. . . . . 23chloroquine phosphate . . . . . 35chlorothiazide . . . . . . . . . .10, 11chlorphen tan/carbetapentane

tan . . . . . . . . . . . . . . . . . . . . 48chlorphen tan/pyrilamine tan/

PE tan . . . . . . . . . . . . . . . . . 48chlorpheniramine extended-

release . . . . . . . . . . . . . . . . 22chlorpheniramine

maleate . . . . . . . . . . . .22, 49chlorpheniramine maleate

phenylephrine HCL . . . . . 49chlorpheniramine tan/

phenylephrine tan. . . . . . . 49chlorpheniramine/

dextromethorphan . . . 49-51chlorpheniramine/

phenylephrine . . . . . . .23, 49chlorpheniramine/

phenylephrine/pyrilamine 23chlorpheniramine/

pseudoephedrine 23, 49, 60chlorpromazine . . . . . . . . .45, 48chlorpromazine hcl inj . . . . . . 45chlorpropamide. . . . . . . . . . . . 25chlorthalidone . . . . . . . . . . . 9, 11chlorzoxazone . . . . . . . . . . . . . 37CHOLBAM . . . . . . . . . . . . . . . . 26cholestyramine . . . . . . . . . . . . 11cholic acid . . . . . . . . . . . . . . . . 26choriogonadotropin alfa . . . . . 39chorionic gonadotropin . . . . . 39ciclopirox . . . . . . . . . . . . . . . . . 20cilostazol . . . . . . . . . . . . . . . . . . 8CILOXAN . . . . . . . . . . . . . . . . . 42cimetidine . . . . . . . . . . . . . . . . 28CIMZIA . . . . . . . . . . . . . . . . . . . 35cinacalcet . . . . . . . . . . . . . . . . . 57CIPRO . . . . . . . . . . . . . . . . . . . 31CIPRODEX . . . . . . . . . . . . . . . . 22ciprofloxacin . . . . . . . 22, 31, 42ciprofloxacin/

dexamethasone . . . . . . . . 22

citalopram . . . . . . . . . . . . . . . . 44CLARAVIS . . . . . . . . . . . . . . . . 18clarithromycin . . . . . . . . . . . . . 31clarithromycin ER . . . . . . . . . . 31CLARITIN . . . . . . . . . . . . . .22, 60CLARITIN-D . . . . . . . . . . . . . . . 50CLEAR EYES REDNESS

RELIEF . . . . . . . . . . . . . . . . 40CLEARASIL . . . . . . . . . . . . . . . 60clemastine . . . . . . . . . . . . . . . . 22CLEOCIN . . . . . . . . . . 18, 35, 39CLEOCIN T . . . . . . . . . . . . . . . 18CLIMARA . . . . . . . . . . . . . . . . . 39clindamycin . . . . . . . . 18, 35, 39CLINORIL . . . . . . . . . . . . . .14, 36clobazam . . . . . . . . . . . . . . . . . 16clobetasol propionate. . . . . . . 19clomipramine. . . . . . . . . . . . . . 43clonazepam . . . . . . . . . . . .16, 43clonidine. . . . . . . . . . . . . . . . . . . 9clonidine transdermal . . . . . . . . 9clopidogrel . . . . . . . . . . . . . . . . . 8clorazepate . . . . . . . . . . . . . . . 43clotrimazole . . . . . 20, 32, 39, 60clotrimazole with

betamethasone . . . . . . . . . 20clozapine . . . . . . . . . . . . . .45, 47clozapine ODT . . . . . . . . . . . . . 45clozapine susp . . . . . . . . . . . . 45CLOZARIL . . . . . . . . . . . . .45, 47cobicistat . . . . . . . . . . . . . . . . . 34cobicistat/elvitegravir/

emtricitabine/tenofovir . . . 34cobimetinib . . . . . . . . . . . . . . . . 4codeine sulfate . . . . . . . . . . . . 14codeine/acetaminophen . . . . 14codeine/chlorpheniramine/

pseudoephedrine . . . . . . . 49codeine/guaifenesin. . . . . . . . 49codeine/guaifenesin/

pseudoephedrine . . . . . . . 49codeine/promethazine. . . . . . 49codeine/promethazine/

phenylephrine . . . . . . . . . . 49CODIMAL DH . . . . . . . . . . . . . 51COGENTIN . . . . . . . . . . . . . . . 16

68

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

Index of Covered DrugsCOLACE . . . . . . . . . . . . . .27, 62COLAZAL . . . . . . . . . . . . . . . . 29COLBENEMID . . . . . . . . . . . . . 37colchicine . . . . . . . . . . . . . . . . . 37colchicine w/ probenecid . . . 37collagenase oint . . . . . . . . . . . 21COLLOIDAL OATMEAL

BATHS . . . . . . . . . . . . . . . . 61COLOCORT. . . . . . . . . . . . . . . 29COLYTE . . . . . . . . . . . . . . . . . . 27COMBIVENT . . . . . . . . . . . . . . 52COMBIVENT RESPIMAT . . . . 52COMBIVIR . . . . . . . . . . . . . . . . 33COMETRIQ . . . . . . . . . . . . . . . . 4COMMIT LOZENGES . . . . . . . 63COMMITT OTC . . . . . . . . . . . . 48COMPAZINE . . . . . . . . . . . . . . 27COMPLERA . . . . . . . . . . . . . . 33COMPLETE NATALCARE PAK

DHA . . . . . . . . . . . . . . . . . . 55COMTAN . . . . . . . . . . . . . . . . . 16condom-male . . . . . . . . . . . . . 61CONDYLOX SOL . . . . . . . . . . 20conjugated estrogen/

bazedoxifene . . . . . . . . . . . 40contraceptive foam . . . . . . . . . 61contraceptive gel . . . . . . . . . . . 61COPAXONE . . . . . . . . . . . . . . . 15COPEGUS . . . . . . . . . . . . . . . . 32CORDARONE . . . . . . . . . . . . . . 9COREG . . . . . . . . . . . . . . . . . . . 9CORGARD . . . . . . . . . . . . . . . . 10CORICIDIN TAB CGH/CLD . . 49CORTAID . . . . . . . . . . . . . . . . . 61CORTEF . . . . . . . . . . . . . . . . . . 24cortisone acetate . . . . . . . . . . 24CORTISPORIN . . . . . . . . .22, 40CORTISPORIN OTIC . . . . . . . 22CORTIZONE . . . . . . . . . . . . . . 19CORTIZONE-10 INTENSIVE

HEALING . . . . . . . . . . . . . . 19COSENTYX . . . . . . . . . . . . . . . 36COSOPT . . . . . . . . . . . . . . . . . 41COTELLIC . . . . . . . . . . . . . . . . . 4COZAAR . . . . . . . . . . . . . . . . . . 9CREON . . . . . . . . . . . . . . . . . . . 29

CREON 3000 UNIT . . . . . . . . 29crisaborole . . . . . . . . . . . . . . . . 21CRIXIVAN . . . . . . . . . . . . . . . . . 34crizotinib . . . . . . . . . . . . . . . . . . . 4crofelemer . . . . . . . . . . . . . . . . 27CROLOM . . . . . . . . . . . . . . . . . 40cromolyn . . . . . . . . . . 23, 40, 53cromolyn sodium . . . . . . .23, 40crotamiton . . . . . . . . . . . . . . . . 20CULTURELLE . . . . . . . . . .29, 62CURITY ALCOHOL PADS . . . 61CUTIVATE . . . . . . . . . . . . . . . . 19cyanocobalamin . . . . . . . . . . . 54CYCLESSA . . . . . . . . . . . . . . . 38cyclobenzaprine . . . . . . . . . . . 37CYCLOGYL . . . . . . . . . . . . . . . 41cyclopentolate . . . . . . . . . . . . . 41CYCLOPHOSPH . . . . . . . . . . . . 4cyclophosphamide . . . . . . . . . . 4cycloserine . . . . . . . . . . . . . . . . 30cyclosporine . . . . . . . . . . . . . . . 6cyclosporine, modified . . . . . . . 6CYMBALTA . . . . . . . . . . . . . . . 44cyproheptadine . . . . . . . . . . . . 22CYSTAGON . . . . . . . . . . . . . . . . 6CYSTARAN . . . . . . . . . . . . . . . 42cysteamine 0.44% ophthalmic

solution . . . . . . . . . . . . . . . 42cysteamine bitartrate . . . . . . . . 6CYTOMEL . . . . . . . . . . . . . . . . 26CYTOTEC . . . . . . . . . . . . . . . . 30CYTOVENE . . . . . . . . . . . . . . . 32CYTOXAN . . . . . . . . . . . . . . . . . 4

DD.H.E. 45 . . . . . . . . . . . . . . . . . 15dabrafenib . . . . . . . . . . . . . . . . . 4daclizumab . . . . . . . . . . . . . . . 15DALMANE . . . . . . . . . . . . . . . . 45danazol . . . . . . . . . . . . . . . . . . . 38DANOCRINE . . . . . . . . . . . . . . 38DANTRIUM . . . . . . . . . . . . . . . 37dantrolene . . . . . . . . . . . . . . . . 37dapsone . . . . . . . . . . . . . . . . . . 35DARAPRIM . . . . . . . . . . . . . . . 35darbepoetin alfa . . . . . . . . . . . . 7

darunavir . . . . . . . . . . . . . . . . . 34darunavir/cobicistat . . . . . . . . 34dasatinib . . . . . . . . . . . . . . . . . . . 4DAYPRO . . . . . . . . . . . . . . .14, 36DDAVP . . . . . . . . . . . . . . . . . . . 26DEBROX . . . . . . . . . . . . . .22, 61DECADRON . . . . . . . . . . . . . . 24decongestants . . . 3, 23, 48, 63deferasirox . . . . . . . . . . . . . . . . . 8DELATESTRYL . . . . . . . . . . . . 24delavirdine . . . . . . . . . . . . . . . . 34DELFEN . . . . . . . . . . . . . . . . . . 61DELSYM . . . . . . . . . . . . . . .50, 61DELTASONE . . . . . . . . . . . . . . 24DELZICOL . . . . . . . . . . . . . . . . 29DEMADEX . . . . . . . . . . . . . . . . 11DEMEROL . . . . . . . . . . . . . . . . 14DEPAKENE . . . . . . . . . . . . . . . 17DEPAKOTE . . . . . . . . 15, 16, 43DEPAKOTE

SPRINKLE . . . . . . 15, 16, 43DEPEN TITRATABLE . . . . . . . 35DEPO-ESTRADIOL . . . . . . . . . 38DEPO-PROVERA . . . . . . . . . . 37DEPO-TESTOSTERONE . . . . 24DERMA-SMOOTHE OIL/FS . 19DERMAPHOR OINTMENT . . 60dermatological baths . . . . . . . 61DERMATOP . . . . . . . . . . . . . . . 19DESCOVY . . . . . . . . . . . . . . . . 34DESENEX . . . . . . . . . . . . . . . . 20desipramine . . . . . . . . . . . . . . . 44desmopressin . . . . . . . . . . . . . 26desmopressin acetate inj . . . . 26desogestrel/EE . . . . . . . . .37, 38desvenlafaxine fumarate tab

SR 24HR . . . . . . . . . . . . . . 45desvenlafaxine succinate tab

SR 24HR . . . . . . . . . . . . . . 45desvenlafaxine tab SR 24HR 45DESYREL . . . . . . . . . . . . . .44, 47DETROL . . . . . . . . . . . . . . . . . . 54dexamethasone . . . . 22, 24, 40dexamethasone sodium

phosphate . . . . . . . . . . . . . 40

69

Index of Covered Drugs

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

DEXASOL . . . . . . . . . . . . . . . . 40dexmethylphenidate . . . . . . . . 43dextromethorphan hbr . . . . . . 50dextromethorphan polistirex

extended-release . . . . . . . 50dextromethorphan-

guaifenesin . . . . . . . . .49, 50dextromethorphan/

brompheniramine/pseudoephedrine . . . . . . . 49

dextromethorphan/guaifenesin 49, 51

dextromethorphan/ promethazine . . . . . . . . . . 50

dextromethorphan/quinidine 47DIABINESE . . . . . . . . . . . . . . . 25DIAMOX SEQUELS . . . . . . . . 41DIASTAT ACUDIAL . . . . . . . . . 16diazepam . . . . . . . . . . 16, 37, 43diclofenac 1% gel . . . . . . . . . . 36diclofenac potassium . . . .13, 36diclofenac sodium 13, 14, 36, 40diclofenac sodium delayed-

release . . . . . . . . . . . . .13, 36diclofenac sodium extended-

release . . . . . . . . . . . . .14, 36dicloxacillin . . . . . . . . . . . . . . . 31dicyclomine . . . . . . . . . . . . . . . 28didanosine . . . . . . . . . . . . . . . . 33didanosine delayed-release . . 33DIDRONEL. . . . . . . . . . . . . . . . 26DIFFERIN OTC GEL 0.1% 18, 60DIFICID . . . . . . . . . . . . . . . . . . . 31DIFLUCAN . . . . . . . . . . . . .32, 39diflunisal . . . . . . . . . . . . . . . . . . 36DIGESTIVE PROBIOTIC .29, 62digoxin . . . . . . . . . . . . . . . . . . . . 9DIHISTINE DH . . . . . . . . . . . . . 49DIHYDRO-PE SYP . . . . . . . . . 51dihydroergotamine . . . . . . . . . 15DILACOR XR . . . . . . . . . . . . . . 10DILANTIN . . . . . . . . . . . . . . . . . 17DILANTIN INFATABS . . . . . . . 17DILAUDID . . . . . . . . . . . . . . . . 14diltiazem . . . . . . . . . . . . . . . . . . 10diltiazem extended-release . . 10

diltiazem sustained-release . . 10DIMEATAPP DRO

DECONGES . . . . . . . . . . . 23dimenhydrinate . . . . . . . . . . . . 62DIMETAPP . . 48, 49, 51, 60, 61DIMETAPP CLD ELX/

ALLERGY . . . . . . . . . . . . . 48DIMETAPP DRO DCON/

CGH . . . . . . . . . . . . . . . . . . 51DIMETAPP DRO

DECONGES . . . . . . . . . . . 61DIMETAPP SYP CGH/CLD . . 49dimethicone lotion 3% . . . . . . 60dimethyl fumarate . . . . . . . . . . 15DIP/TET PED INJ . . . . . . . . . . 58DIPENTUM . . . . . . . . . . . . . . . 29diphenhydramine . . . . . . .22, 45diphenhydramine-

phenylephrine soln . . . . . 23diphenoxylate/atropine . . . . . 27diphtheria-tetanus tox

adsorbed (dt) im . . . . . . . . 58DIPROLENE . . . . . . . . . . . . . . 19DIPROLENE AF . . . . . . . . . . . 19dipyridamole . . . . . . . . . . . . . . . 8DISALCID . . . . . . . . . . . . . . . . . 36disopyramide . . . . . . . . . . . . . . . 9disopyramide

extended-release . . . . . . . . 9disulfiram . . . . . . . . . . . . . . . . . 42DITROPAN . . . . . . . . . . . . . . . . 53DITROPAN XL . . . . . . . . . . . . . 53DIURIL . . . . . . . . . . . . . . . .10, 11DIURIL ORAL SUSPENSION 11divalproex sodium cap

sprinkle . . . . . . . . 15, 16, 43divalproex sodium delayed-

release . . . . . . . . . 15, 16, 43docosanol . . . . . . . . . . . . .33, 60docusate calcium plus . . . . . . 27docusate potasssium . . . . . . . 27docusate sodium . . . . . . . . . . 27dofetilide. . . . . . . . . . . . . . . . . . . 9DOK . . . . . . . . . . . . . . . . . . . . . 27DOLOBID . . . . . . . . . . . . . . . . . 36

dolutegravir . . . . . . . . . . . .33, 34dolutegravir/rilpivirine . . . . . . . 34DOMEBORO . . . . . . . . . . .22, 61DOMEBORO OTIC . . . . . . . . . 22donepezil . . . . . . . . . . . . . . . . . 13dornase alfa . . . . . . . . . . . . . . . 57dorzolamide . . . . . . . . . . . . . . . 41dorzolamide/timolol maleate 41DOSTINEX . . . . . . . . . . . . . . . . 26DOVONEX . . . . . . . . . . . . . . . . 20doxazosin . . . . . . . . . . . . . . . 9, 53doxepin . . . . . . . . . . . . . . . . . . 44doxycycline hyclate . . . . . . . . . 31doxycycline monohydrate . . . 31doxylamine succinate . . . .45, 62DRAMAMINE . . . . . . . . . . . . . 62DRISDOL . . . . . . . . . . . . . . . . . 54dronabinol . . . . . . . . . . . . . . . . 27DROXIA . . . . . . . . . . . . . . . . . . . 6DUAVEE . . . . . . . . . . . . . . . . . . 40dulaglutide . . . . . . . . . . . . . . . . 26DULCOLAX . . . . . . . . . . . . . . . 62duloxetine . . . . . . . . . . . . .44, 46DUOFILM . . . . . . . . . . . . . .20, 63DUONEB . . . . . . . . . . . . . . . . . 53DURAGESIC . . . . . . . . . . . . . . 14DURATUSS DM ELX . . . . . . . 49DUREX . . . . . . . . . . . . . . . . . . . 61DURICEF . . . . . . . . . . . . . . . . . 30DYAZIDE . . . . . . . . . . . . . . . . . 11

EE-OINTMENT . . . . . . . . . . . . . 60E.E.S. . . . . . . . . . . . . . . . . . . . . 31ecothiophate . . . . . . . . . . . . . . 41ECOTRIN . . . . . . . . . . . 7, 36, 63ED A-HIST TABLETS AND

LIQUID . . . . . . . . . . . . . . . . 49EDGE OB CHW . . . . . . . . . . . 55edoxaban . . . . . . . . . . . . . . . . . . 7EDURANT . . . . . . . . . . . . . . . . 34efavirenz . . . . . . . . . . . . . . .33, 34efavirenz/emtricitabine/

tenofovir . . . . . . . . . . . . . . . 33EFFEXOR . . . . . . . . . . . . . . . . . 44EFFEXOR XR . . . . . . . . . . . . . . 44

70

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

Index of Covered DrugsEFFIENT . . . . . . . . . . . . . . . . . . . 8EFUDEX . . . . . . . . . . . . . . . . . . 21EGRIFTA . . . . . . . . . . . . . . . . . 26ELAVIL . . . . . . . . . . . . . . . .15, 44ELDEPRYL . . . . . . . . . . . . . . . . 16electrolyte . . . . . . . . . . . . . .54, 62electrolyte rehydrating soln . . 62ELIDEL . . . . . . . . . . . . . . . . . . . 21ELIMITE . . . . . . . . . . . . . . . . . . 20ELIQUIS . . . . . . . . . . . . . . . . . . . 7ELMIRON . . . . . . . . . . . . . . . . . 54ELOCON . . . . . . . . . . . . . . . . . 19eltrombopag . . . . . . . . . . . . . . 57elvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate . . . 34

EMCYT . . . . . . . . . . . . . . . . . . . . 4EMEND . . . . . . . . . . . . . . . . . . 27EMETROL . . . . . . . . . . . . . . . . 62emicizumab-kxwh . . . . . . . . . . . 8EMLA . . . . . . . . . . . . . . . . . . . . 21emollients . . . . . . . . . . . . . . . . . 60EMSAM . . . . . . . . . . . . . . . . . . 47emtricitabine . . . . . . . . . . .33, 34emtricitabine/rilpivirine/

tenofovir . . . . . . . . . . . . . . . 33emtricitabine/tenofovir . . .33, 34emtricitabine/tenofovir

alafenamide . . . . . . . . . . . . 34EMTRIVA . . . . . . . . . . . . . . . . . 33enalapril . . . . . . . . . . . . . . . . . . . 8enalapril oral soln . . . . . . . . . . . 8enalapril/hydrochlorothiazide . 8ENBREL . . . . . . . . . . . . . . . . . . 35enfuvirtide . . . . . . . . . . . . . . . . 34ENGERIX-B . . . . . . . . . . . . . . . 58enoxaparin . . . . . . . . . . . . . . . . . 7entacapone . . . . . . . . . . . . . . . 16entecavir . . . . . . . . . . . . . . . . . . 32ENTERIC COATED-

NAPROSYN . . . . . . . . .14, 36ENTOCORT EC . . . . . . . . . . . . 29ENTRESTO . . . . . . . . . . . . . . . . 9ENULOSE . . . . . . . . . . . . . . . . 27EPANED . . . . . . . . . . . . . . . . . . . 8epinephrine . . . . . . . . . . . . . . . 57

EPIPEN . . . . . . . . . . . . . . . . . . . 57EPIPEN JR. . . . . . . . . . . . . . . . 57EPIVIR . . . . . . . . . . . . . . . .32, 33EPIVIR HBV . . . . . . . . . . . . . . . 32epoetin alfa . . . . . . . . . . . . . . . . 7EPOGEN . . . . . . . . . . . . . . . . . . 7EPZICOM . . . . . . . . . . . . . . . . . 33EQL B COMPLEX . . . . . . . . . . 54EQUETRO . . . . . . . . . . . . . . . . 45ergocalciferol (D2) . . . . . . . . . 54ergotamine tartrate/caffeine . 15ergotamine/caffeine . . . . . . . . 15ERIVEDGE . . . . . . . . . . . . . . . . . 7erlotinib . . . . . . . . . . . . . . . . . . . 4ertugliflozin . . . . . . . . . . . . . . . 25ertugliflozin/metformin . . . . . . 25ERY-TAB . . . . . . . . . . . . . . . . . . 31ERYC . . . . . . . . . . . . . . . . . . . . 31ERYGEL . . . . . . . . . . . . . . . . . . 18ERYTHROCIN . . . . . . . . . . . . . 31erythromycin . . . . . . . 18, 31, 42erythromycin delayed-release 31erythromycin ethylsuccinate . 31erythromycin stearate . . . . . . . 31erythromycin/benzoyl

peroxide . . . . . . . . . . . . . . . 18erythromycin/sulfisoxazole . . 31ESBRIET . . . . . . . . . . . . . . . . . 57escitalopram . . . . . . . . . . .44, 46escitalopram & methylfolate-

B12-B6-D cap thpk . . . . . 46escitalopram oxalate soln . . . 46ESGIC . . . . . . . . . . . . . . . . . . . . 13ESKALITH CR . . . . . . . . . . . . . 43esomeprazole . . . . . . . . . . . . . 28esomeprazole granules . . . . . 28estazolam . . . . . . . . . . . . . . . . . 45ESTRACE . . . . . . . . . . . . . . . . . 39ESTRACE CRM. . . . . . . . . . . . 39estradiol . . . . . . . . . . . . . . .38, 39estradiol cypionate . . . . . . . . . 38estradiol td . . . . . . . . . . . . . . . . 39estradiol vaginal tablet . . . . . . 39estramustine phosphate sodium 4estrogens, conjugated . . . . . . 39

estrogens, conjugated/medroxyprogesterone . . . 39

estrogens, conjugated, synthetic A . . . . . . . . . . . . . 39

estropipate . . . . . . . . . . . . . . . . 39etanercept . . . . . . . . . . . . . . . . 35ethambutol . . . . . . . . . . . . . . . . 30ethionamide . . . . . . . . . . . . . . . 30ethosuximide . . . . . . . . . . . . . . 16ethynodiol diacetate/EE . . . . . 38etidronate . . . . . . . . . . . . . . . . . 26etodolac . . . . . . . . . . . . . . .14, 36etonogestrel/EE . . . . . . . . . . . 37etoposide . . . . . . . . . . . . . . . . . . 6etravirine . . . . . . . . . . . . . . . . . . 34EUCRISA . . . . . . . . . . . . . . . . . 21EULEXIN . . . . . . . . . . . . . . . . . . 5EURAX . . . . . . . . . . . . . . . . . . . 20everolimus . . . . . . . . . . . . . . . 5, 6EVISTA . . . . . . . . . . . . . . . . . . . 26EXCEDRIN MIGRAINE . . . . . . 13EXELON . . . . . . . . . . . . . . . . . . 13exemestane . . . . . . . . . . . . . . . . 5EXJADE . . . . . . . . . . . . . . . . . . . 8ezetimibe . . . . . . . . . . . . . . . . . 11ezogabine . . . . . . . . . . . . . . . . 16

FFABB . . . . . . . . . . . . . . . . . . . . 54famotidine . . . . . . . . . . . . .28, 62FANAPT . . . . . . . . . . . . . . . . . . 46FANTASY . . . . . . . . . . . . . . . . . 61FARESTON . . . . . . . . . . . . . . . . 5FARYDAK . . . . . . . . . . . . . . . . . . 4FAZACLO . . . . . . . . . . . . . . . . . 45febuxostat . . . . . . . . . . . . . . . . 37felbamate . . . . . . . . . . . . . .16, 17felbamate oral susp . . . . . . . . 17FELBATOL . . . . . . . . . . . . .16, 17FELBATOL ORAL SUSP . . . . 17FELDENE . . . . . . . . . . . . . .14, 36felodipine extended-release . 10FEMARA . . . . . . . . . . . . . . . . . . 5fenofibrate . . . . . . . . . . . . . . . . 11fentanyl transdermal . . . . . . . . 14FEOSOL . . . . . . . . . . . . . . .54, 63

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Index of Covered Drugs

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

FERGON . . . . . . . . . . . . . . . . . 63ferrous bis-glycinate chelate . 63ferrous bisglycinate/

polysaccarides iron . . . . . 54ferrous fumarate . . . . . . . . . . . 63ferrous gluconate . . . . . . . . . . 63ferrous sulfate . . . . . . . . . .54, 63FETZIMA . . . . . . . . . . . . . . . . . 46fidaxomicin . . . . . . . . . . . . . . . 31filgrastim . . . . . . . . . . . . . . . . . . . 7FINACEA . . . . . . . . . . . . . . . . . 18finasteride . . . . . . . . . . . . . . . . 53fingolimod . . . . . . . . . . . . . . . . 15FIORICET W/CODEINE . . . . . 14FIORINAL . . . . . . . . . . . . . .13, 14FIORINAL W/CODEINE . . . . . 14FIRAZYR . . . . . . . . . . . . . . . . . 57FISH OIL . . . . . . . . . . . . . . . . . . 11fish oil caps . . . . . . . . . . . . . . . 11FLAGYL . . . . . . . . . . . . . . .35, 39FLAVOXATE . . . . . . . . . . . . . . 53flavoxate hcl . . . . . . . . . . . . . . . 53flecainide . . . . . . . . . . . . . . . . . . 9FLEET ENEMA . . . . . . . . . . . . 62FLEET PHOSPHO-SODA . . . 62FLEXERIL . . . . . . . . . . . . . . . . . 37FLOMAX. . . . . . . . . . . . . . . . . . 53FLONASE . . . . . . . . . . . . . . . . . 23FLORAJEN . . . . . . . . . . . .29, 62FLORANEX . . . . . . . . . . . .29, 62FLORASTOR . . . . . . . . . . .29, 62FLORINEF . . . . . . . . . . . . . . . . 24FLOXIN . . . . . . . . . . . . . . . .22, 31FLOXIN OTIC . . . . . . . . . . . . . . 22FLUARIX QUAD . . . . . . . . . . . 58FLUBLOK . . . . . . . . . . . . . . . . . 58FLUCELVAX . . . . . . . . . . . . . . . 58fluconazole . . . . . . . . . . . .32, 39fludrocortisone . . . . . . . . . . . . 24FLULAVAL QUAD . . . . . . . . . . 58FLUMADINE . . . . . . . . . . . . . . 33fluocinolone acetonide . . . . . . 19fluocinonide . . . . . . . . . . . . . . . 19fluocinonide emulsified base 19fluoride . . . . . . . . . . . . . 54-56, 63fluoride dental rinse . . . . . . . . 63

fluorometholone . . . . . . . .40, 41fluorouracil . . . . . . . . . . . . . . . . 21fluoxetine . . . . . . . . . . . . . .44, 46fluoxetine capsule . . . . . . . . . . 46fluoxetine HCL cap delayed

release 90 mg . . . . . . . . . . 46fluoxetine tablet . . . . . . . . . . . . 46fluphenazine . . . . . . . . . . . . . . 48fluphenazine decanoate . . . . 48flurazepam . . . . . . . . . . . . . . . . 45flurbiprofen . . . . . . . . . . . . . . . 40flutamide . . . . . . . . . . . . . . . . . . 5fluticasone . . . . . . . . . 19, 23, 52fluticasone furoate . . . . . . . . . 52fluticasone propionate . . . . . . 19fluticasone/salmeterol . . . . . . 52fluticasone/vilanterol . . . . . . . 52FLUVIRIN . . . . . . . . . . . . . . . . . 58fluvoxamine . . . . . . . . . . . .43, 46fluvoxamine maleate cap SR

24HR . . . . . . . . . . . . . . . . . 46FLUZONE HD PF . . . . . . . . . . 58FLUZONE QUAD. . . . . . . . . . . 58FLUZONE SPLT . . . . . . . . . . . 58FML . . . . . . . . . . . . . . . . . . .40, 41FML FORTE . . . . . . . . . . . . . . . 41FML LIQUIFILM . . . . . . . . . . . . 41FOCALIN . . . . . . . . . . . . . . . . . 43folic acid . . . . . . . . . . . . . . .54, 56folic acid-vitamin b6-vitamin

b12 . . . . . . . . . . . . . . . . . . . 54FOLTABS PAK PLUS DHA RE

OB + DHA PAK . . . . . . . . . 55FOLTABS PRENATAL . . . . . . . 56FORFIVO XL . . . . . . . . . . . . . . 45FORTICAL . . . . . . . . . . . . . . . . 26FOSAMAX . . . . . . . . . . . . . . . . 26fosamprenavir . . . . . . . . . . . . . 34fosinopril. . . . . . . . . . . . . . . . . . . 8fosinopril/hydrochlorothiazide 8FURADANTIN SUSP

25 MG/5 ML . . . . . . . . . . . 35furosemide . . . . . . . . . . . . . . . . 11FUZEON . . . . . . . . . . . . . . . . . . 34

Ggabapentin . . . . . . . . . . . . . . . . 17GABITRIL . . . . . . . . . . . . . . . . . 17galantamine . . . . . . . . . . . . . . . 13ganciclovir . . . . . . . . . . . . . . . . 32GARDASIL . . . . . . . . . . . . . . . . 58GARDASIL 9 . . . . . . . . . . . . . . 58gatifloxin . . . . . . . . . . . . . . . . . . 42GATTEX . . . . . . . . . . . . . . . . . . 30gefitinib . . . . . . . . . . . . . . . . . . . . 5GEL-KAM . . . . . . . . . . . . . . . . . 54gemfibrozil . . . . . . . . . . . . . . . . 11GENGRAF . . . . . . . . . . . . . . . . . 6GENTAK . . . . . . . . . . . . . . .18, 42gentamicin . . . . . . . . . 18, 40, 42gentamicin/prednisolone

acetate . . . . . . . . . . . . . . . . 40GENTEX ADE 28-1 MG . . . . . 55GENVOYA . . . . . . . . . . . . . . . . 34GEODON . . . . . . . . . . . . . . . . . 47GERAVIM . . . . . . . . . . . . . . . . . 54GG/CODEINE . . . . . . . . . . . . . 49GG/DM CR . . . . . . . . . . . . . . . 49GILENYA . . . . . . . . . . . . . . . . . 15GILOTRIF . . . . . . . . . . . . . . . . . . 4glatiramer acetate . . . . . . .15, 16GLATOPA . . . . . . . . . . . . . . . . . 16glecaprevir/pibrentasvir . . . . . 32GLEEVEC . . . . . . . . . . . . . . . . . 5GLEOSTINE . . . . . . . . . . . . . . . . 4glimepiride . . . . . . . . . . . . . . . . 25glipizide . . . . . . . . . . . . . . . . . . 25glipizide extended-release . . . 25glipizide-metformin . . . . . . . . . 25GLUCAGON . . . . . . . . . . . . . . 24glucagon, human

recombinant . . . . . . . . . . . 24GLUCOPHAGE . . . . . . . . . . . . 25GLUCOPHAGE ER . . . . . . . . . 25glucose gel 40% . . . . . . . . . . . 61glucose oral tablets . . . . . . . . 61GLUCOTROL . . . . . . . . . . . . . 25GLUCOTROL XL . . . . . . . . . . . 25GLUCOVANCE . . . . . . . . . . . . 25GLUTOSE 15 . . . . . . . . . . . . . 61

72

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

Index of Covered Drugsglyburide . . . . . . . . . . . . . . . . . 25glyburide, micronized . . . . . . . 25glycerin . . . . . . . . . . . . 27, 40, 60GLYCERIN SUPPOSITORY . . 27GLYCERIN TOPICAL . . . . . . . 60glycerol phenylbutyrate . . . . . 58glycopyrrolate . . . . . . . . . . . . . 28GLYNASE . . . . . . . . . . . . . . . . . 25GRIFULVIN V . . . . . . . . . . . . . . 32GRIS-PEG . . . . . . . . . . . . . . . . 32griseofulvin microsize . . . . . . . 32griseofulvin ultramicrosize . . . 32guaifenesin . . . . . . . . . . . . 49-51guaifenesin extended-release 50guaifenesin/

pseudoephedrine . . . .49, 50guaifenesin/pseudoephedrine

extended-release . . . . . . . 50guaifenesin/pseudoephedrine/

dextromethorphan . . . . . . 50guanabenz . . . . . . . . . . . . . . . . 12guanfacine . . . . . . . . . . . . . . 9, 43guanfacine ER . . . . . . . . . . . . . 43GUIATUSS AC . . . . . . . . . . . . . 49GUIATUSS DAC . . . . . . . . . . . 49GYNE-LOTRIMIN . . . . . . .39, 60GYNOL II . . . . . . . . . . . . . . . . . 61

HHAEGARDA . . . . . . . . . . . . . . . 57HALCION . . . . . . . . . . . . . . . . . 45HALDOL . . . . . . . . . . . . . . . . . . 48HALDOL DECANOATE . . . . . 48halobetasol . . . . . . . . . . . . . . . 19haloperidol . . . . . . . . . . . . . . . . 48haloperidol decanoate . . . . . . 48HAVRIX . . . . . . . . . . . . . . . . . . . 58HECORIA . . . . . . . . . . . . . . . . . . 6HEMLIBRA . . . . . . . . . . . . . . . . 8heparin . . . . . . . . . . . . . . . . . . . . 7hepatitis a vaccine susp . . . . . 58hepatitis b vaccine

(recombinant) . . . . . . . . . . 58hepatitis b vaccine recombinant

adjuvanted . . . . . . . . . . . . . 58HEPLISAV-B . . . . . . . . . . . . . . 58

HETLIOZ . . . . . . . . . . . . . . . . . 47HEXALEN . . . . . . . . . . . . . . . . . 4HIPREX . . . . . . . . . . . . . . . . . . 53homatropine . . . . . . . . . . .41, 50HUMALOG MIX 50/50. . . . . . 25HUMALOG MIX 75/25. . . . . . 25human papillomavirus (hpv)

9-valent recomb vac . . . . . 58human papillomavirus (hpv)

quadrivalent recombinant vac . . . . . . . . . . . . . . . . . . . 58

HUMATIN . . . . . . . . . . . . . . . . . 35HUMIRA . . . . . . . . . . . . . . . . . . 35HUMULIN. . . . . . . . . . 24, 25, 61HUMULIN 70/30 . . . . . . . . . . 25HUMULIN N . . . . . . . . . . . . . . . 24HUMULIN R . . . . . . . . . . . . . . . 25HYCAMTIN . . . . . . . . . . . . . . . . 7HYCODAN . . . . . . . . . . . . . . . . 50hydralazine. . . . . . . . . . . . . . . . 12HYDREA . . . . . . . . . . . . . . . . . . 6hydrochlorothiazide . . . . . . 8-11hydrocodone ER . . . . . . . . . . . 14hydrocodone/

acetaminophen . . . . . . . . . 14hydrocodone/homatropine . . 50HYDROCODONE/TAB

HOMATROP . . . . . . . . . . . 50hydrocortisone

. .19, 21, 22, 24, 29, 40, 61hydrocortisone butyrate . . . . . 19hydrocortisone crm, oint . . . . 61hydrocortisone valerate . . . . . 19hydrocortisone/aloe . . . . . . . . 19HYDROMET SYP . . . . . . . . . . 50hydromorphone . . . . . . . . . . . 14hydroxychloroquine . . . . . . . . 35hydroxyurea . . . . . . . . . . . . . . . . 6hydroxyzine HCL . . . . . . . . . . . 22hydroxyzine pamoate . . . . . . . 22hyoscyamine . . . . . . . . . . .28, 53hyoscyamine sulfate . . . . . . . . 28hyoscyamine sulfate extended-

release . . . . . . . . . . . . . . . . 28HYPERCARE 15% . . . . . . . . . 20HYPERSAL . . . . . . . . . . . . . . . 57

HYPERTET S/D . . . . . . . . . . . 59HYPOTEARS . . . . . . . . . . . . . . 63HYTONE . . . . . . . . . . . . . . . . . 19HYTRIN . . . . . . . . . . . . . . . . 9, 53HYZAAR . . . . . . . . . . . . . . . . . . 9

IIBRANCE . . . . . . . . . . . . . . . . . . 5ibrutinib . . . . . . . . . . . . . . . . . . . 5IBUOROFEN TAB COLD/

SIN . . . . . . . . . . . . . . . . . . . 51ibuprofen . . . . . . . . . . 14, 36, 63ibuprofen tabs, chew tabs,

susp, and drops . . . . . . . . 63icatibant . . . . . . . . . . . . . . . . . . 57ICLUSIG . . . . . . . . . . . . . . . . . . . 5idelalisib . . . . . . . . . . . . . . . . . . . 5ILARIS . . . . . . . . . . . . . . . . . . . 35iloperidone . . . . . . . . . . . . . . . . 46imatinib mesylate . . . . . . . . . . . 5IMBRUVICA . . . . . . . . . . . . . . . . 5IMDUR . . . . . . . . . . . . . . . . . . . 12imipramine HCL . . . . . . . . . . . 44imipramine pamoate . . . . . . . 46imiquimod 5% cream . . . . . . . 21IMITREX . . . . . . . . . . . . . . . . . . 15IMITREX 4 MG AND

6 MG INJ . . . . . . . . . . . . . . 15IMODIUM A-D . . . . . . . . . .27, 62IMPAVIDO . . . . . . . . . . . . . . . . 32IMURAN . . . . . . . . . . . . . . . . 6, 35INCRELEX . . . . . . . . . . . . . . . . 26INCRUSE ELLIPTA . . . . . . . . . 52indacaterol . . . . . . . . . . . . . . . . 52indapamide . . . . . . . . . . . . . . . 11INDERAL . . . . . . . . . . . . . .10, 15INDERAL LA . . . . . . . . . . . . . . 10INDERIDE . . . . . . . . . . . . . . . . 10indinavir . . . . . . . . . . . . . . . . . . 34INDOCIN . . . . . . . . . . . . . .14, 36indomethacin . . . . . . . . . .14, 36INFLAMASE FORTE . . . . . . . . 41influenza virus vaccine

recombinant hemagglutinin (ha) . . . . . . . . . . . . . . . . . . . 58

influenza virus vaccine split . . 58

73

Index of Covered Drugs

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

influenza virus vaccine split high-dose pf . . . . . . . . . . . 58

influenza virus vaccine split pf . . . . . . . . . . . . . . . . . . . . . 58

influenza virus vaccine split quadrivalent . . . . . . . . . . . . 58

influenza virus vaccine tiss-cult subunit . . . . . . . . . . . . . . . . 58

influenza virus vaccine types a&b surface antigen . . . . . 58

INGREZZA . . . . . . . . . . . . . . . . 17INLYTA . . . . . . . . . . . . . . . . . . . . 4inositol niacinate . . . . . . . . . . . 11insulin (vials only) . . . . . . . . . . 61insulin aspart protamine 70%/

insulin aspart 30% . . . . . . 24insulin glargine . . . . . . . . . . . . 24insulin glargine 300 unit/ml . 24insulin glargine/lixisenatide . . 24insulin human . . . . . . . . . . . . . 24insulin isophane . . . . . . . .24, 25insulin isophane human . .24, 25insulin isophane human 70%/

regular 30% . . . . . . . . . . . . 25insulin isophane/regular . . . . 25insulin lisopro pro/lispro . . . . 25insulin lisopro prot/lispro . . . . 25insulin lispro . . . . . . . . . . . . . . . 25insulin regular . . . . . . . . . . . . . 25insulin syringes . . . . . . . . . . . . 57INTAL . . . . . . . . . . . . . . . . . . . . 53INTELENCE . . . . . . . . . . . . . . . 34interferon alfa-2b . . . . . . . . . 6, 32interferon gamma-1b . . . . . . . . 6INTRON A . . . . . . . . . . . . . . 6, 32INTUNIV . . . . . . . . . . . . . . . . . . 43INVEGA . . . . . . . . . . . . . . .46, 47INVEGA SUSTENNA . . . . . . . 47INVEGA TRINZA . . . . . . . . . . . 47INVIRASE . . . . . . . . . . . . . . . . . 34ipratropium . . . . . . . . 23, 52, 53ipratropium HFA . . . . . . . . . . . 52ipratropium nasal . . . . . . . . . . 23ipratropium/albuterol . . . .52, 53IRENKA . . . . . . . . . . . . . . . . . . 46IRESSA . . . . . . . . . . . . . . . . . . . . 5

iron . . . . . . . . . . . . 38, 54-56, 63iron polysaccharides . . . . . . . 63ISENTRESS . . . . . . . . . . . . . . . 33ISENTRESS CHEWABLE . . . 33ISENTRESS HD . . . . . . . . . . . 33ISENTRESS SUSP . . . . . . . . . 33ISMO . . . . . . . . . . . . . . . . . . . . . 12isocarboxazid . . . . . . . . . . . . . 46isoniazid . . . . . . . . . . . . . . . . . . 30ISOPTO ATROPINE . . . . . . . . 41ISOPTO CARPINE . . . . . . . . . 41ISOPTO HOMATROPINE. . . . 41ISOPTO HYOSCINE . . . . . . . . 41ISORDIL . . . . . . . . . . . . . . . . . . 12ISORDIL S.L. . . . . . . . . . . . . . . 12isosorbide dinitrate . . . . . . . . . 12ISOSORBIDE DINITRATE ER 12isosorbide dinitrate extended-

release . . . . . . . . . . . . . . . . 12isosorbide mononitrate . . . . . 12isosorbide mononitrate extended-

release . . . . . . . . . . . . . . . . 12isotretinoin . . . . . . . . . . . . . . . . 18itraconazole . . . . . . . . . . . . . . . 32ivacaftor . . . . . . . . . . . . . . . . . . 57ivermectin . . . . . . . . . . . . . . . . 30ixazomib . . . . . . . . . . . . . . . . . . . 5

JJADENU . . . . . . . . . . . . . . . . . . . 8JAKAFI . . . . . . . . . . . . . . . . . . . . 5JULUCA . . . . . . . . . . . . . . . . . . 34

KK-DUR 10 . . . . . . . . . . . . . . . . . 56K-DUR 20 . . . . . . . . . . . . . . . . . 56K-LOR . . . . . . . . . . . . . . . . . . . . 56K-LYTE . . . . . . . . . . . . . . . . . . . 56K-PHOS NEUTRAL . . . . . . . . . 56K-PHOS ORIGINAL . . . . . . . . 56KALETRA . . . . . . . . . . . . . . . . 34KALEXATE . . . . . . . . . . . . . . . . 12KALYDECO . . . . . . . . . . . . . . . 57KALYDECO GRANULES . . . . 57KAOPECTATE . . . . . . . . . . . . . 62KAYEXALATE . . . . . . . . . . . . . 12

KAZANO . . . . . . . . . . . . . . . . . 25KEFLEX . . . . . . . . . . . . . . . . . . 30KENALOG . . . . . . . . . . . . .19, 23KENALOG IN ORABASE . . . . 23KEPPRA (NOT XR) . . . . . . . . . 17KERLONE . . . . . . . . . . . . . . . . . 9ketoconazole . . . . . . . 20, 21, 32ketoprofen . . . . . . . . . . . . .14, 36ketorolac . . . . . . . . . . . . . .14, 40ketorolac tromethamine . . . . . 14ketotifen . . . . . . . . . . . . . . . . . . 40KEVZARA . . . . . . . . . . . . . . . . 35KHEDEZLA . . . . . . . . . . . . . . . 45KIMONO. . . . . . . . . . . . . . . . . . 61KINERET . . . . . . . . . . . . . . . . . 35KLARON . . . . . . . . . . . . . . . . . 18KLONOPIN . . . . . . . . . . . .16, 43KLOR-CON 10 . . . . . . . . . . . . 56KLOR-CON 8 . . . . . . . . . . . . . 56KONSYL-D . . . . . . . . . . . . . . . . 62KORLYM . . . . . . . . . . . . . . . . . 26KUVAN . . . . . . . . . . . . . . . . . . . 26KUVAN POWDER FOR

SOLUTION . . . . . . . . . . . . 26

Llabetalol . . . . . . . . . . . . . . . . . . 10LAC-HYDRIN . . . . . . . . . . . . . . 21lacosamide . . . . . . . . . . . . . . . 17LACTINEX . . . . . . . . . . . . .29, 62LACTINOL . . . . . . . . . . . . . . . . 21lactulose . . . . . . . . . . . . . . . . . . 27LAMICTAL . . . . . . . . . . . . . . . . 17LAMICTAL CD CHEW TAB . . 17LAMICTAL STARTER KIT . . . 17LAMISIL . . . . . . . . . . . . . . .20, 32LAMISIL AT . . . . . . . . . . . .20, 32LAMISIL AT SPRAY . . . . . . . . 32lamivudine . . . . . . . . . . . . . 32-34lamivudine/zidovudine . . . . . . 33lamotrigine . . . . . . . . . . . . . . . . 17lamotrigine chew dispersable

tab . . . . . . . . . . . . . . . . . . . . 17lamotrigine starter kit . . . . . . . 17lancets . . . . . . . . . . . . . . . . . . . 57LANOXIN . . . . . . . . . . . . . . . . . . 9

74

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

Index of Covered Drugslansoprazole . . . . . . . . . . . . . . 28lansoprazole delayed-release 28lapatinib ditosylate . . . . . . . . . . 5LARIAM . . . . . . . . . . . . . . . . . . 35LASIX . . . . . . . . . . . . . . . . . . . . 11latanoprost . . . . . . . . . . . . . . . . 41LATUDA . . . . . . . . . . . . . . . . . . 46laxative enemas . . . . . . . . . . . 62laxatives . . . . . . . . . . . . 2, 27, 62leflunomide . . . . . . . . . . . . . . . 35lenalidomide . . . . . . . . . . . . . . . 6lenvatinib . . . . . . . . . . . . . . . . . . 5LENVIMA . . . . . . . . . . . . . . . . . . 5LETAIRIS . . . . . . . . . . . . . . . . . 12letrozole . . . . . . . . . . . . . . . . . . . 5leucovorin . . . . . . . . . . . . . . . 5, 7leucovorin calcium . . . . . . . . . . 7LEUKERAN . . . . . . . . . . . . . . . . 4LEUKINE . . . . . . . . . . . . . . . . . . 7leuprolide . . . . . . . . . . . . . . . . . . 6levalbuterol HCl . . . . . . . . . . . . 53LEVAQUIN . . . . . . . . . . . . . . . . 31levetiracetam . . . . . . . . . . . . . . 17levobunolol . . . . . . . . . . . . . . . 41levocetirizine . . . . . . . . . . . . . . 22levofloxacin . . . . . . . . . . . . . . . 31levomilnacipran . . . . . . . . . . . . 46levonorgestrel . . . . . . . . . .37, 38levonorgestrel/EE . . . . . . .37, 38levothyroxine . . . . . . . . . . . . . . 26LEVOXYL . . . . . . . . . . . . . . . . . 26LEVSIN . . . . . . . . . . . . . . . . . . . 28LEVSINEX . . . . . . . . . . . . . . . . 28LEXAPRO . . . . . . . . . . . . .44, 46LEXAPRO SOLUTION . . . . . . 46LEXIVA . . . . . . . . . . . . . . . . . . . 34LIBRIUM . . . . . . . . . . . . . . . . . . 42LIDAMANTEL . . . . . . . . . . . . . 21LIDEX . . . . . . . . . . . . . . . . . . . . 19LIDEX E . . . . . . . . . . . . . . . . . . 19lidocaine . . . . . . . . . . . . . . .21, 23lidocaine patch . . . . . . . . . . . . 21lidocaine viscous . . . . . . . . . . 23lidocaine/prilocaine . . . . . . . . 21LIDODERM . . . . . . . . . . . . . . . 21LIFESTYLES . . . . . . . . . . . . . . 61

lifitegrast . . . . . . . . . . . . . . . . . . 42LIMBITROL . . . . . . . . . . . . . . . 44linaclotide . . . . . . . . . . . . . . . . . 27linezolid . . . . . . . . . . . . . . . . . . 35LINZESS . . . . . . . . . . . . . . . . . . 27liothyronine . . . . . . . . . . . . . . . 26liotrix . . . . . . . . . . . . . . . . . . . . . 26LIPITOR . . . . . . . . . . . . . . . . . . 11LIPOFEN . . . . . . . . . . . . . . . . . 11lisdexamfetamine . . . . . . . . . . 43lisdexamfetamine chewable

tab . . . . . . . . . . . . . . . . . . . . 43lisinopril . . . . . . . . . . . . . . . . 8, 85lisinopril/hydrochlorothiazide . 8lithium carbonate . . . . . . . . . . 43lithium carbonate extended-

release . . . . . . . . . . . . . . . . 43LITHOBID . . . . . . . . . . . . . . . . . 43lixisenatide . . . . . . . . . . . . .24, 26LMX-4 . . . . . . . . . . . . . . . . . . . . 21LO/OVRAL . . . . . . . . . . . . . . . . 38LOCOID . . . . . . . . . . . . . . . . . . 19LODINE . . . . . . . . . . . . . . .14, 36LOESTRIN 1/20 . . . . . . . . . . . 37LOESTRIN 1.5/30 . . . . . . . . . 38LOESTRIN FE 1/20 . . . . . . . . 38LOESTRIN FE 1.5/30 . . . . . . . 38LOFIBRA . . . . . . . . . . . . . . . . . 11LOHIST-D . . . . . . . . . . . . . . . . . 49LOMOTIL . . . . . . . . . . . . . . . . . 27lomustine . . . . . . . . . . . . . . . . . . 4LONITEN . . . . . . . . . . . . . . . . . 12LONSURF . . . . . . . . . . . . . . . . . 4loperamide . . . . . . . . . . . . . . . . 27LOPID . . . . . . . . . . . . . . . . . . . . 11lopinavir/ritonavir . . . . . . . . . . 34LOPRESSOR . . . . . . . . . . . . . . 10loratadine . . . . . . . 22, 23, 50, 61loratadine & pseudoephedrine

SR 24hr . . . . . . . . . . . . . . . 50loratadine/

pseudoephedrine 23, 50, 61loratadine/pseudoephedrine

extended-release . . . . . . . 23lorazepam . . . . . . . . . . . . . . . . 43LORCET . . . . . . . . . . . . . . . . . . 14

LORTAB . . . . . . . . . . . . . . . . . . 14LORTAB ELIXIR . . . . . . . . . . . 14losartan . . . . . . . . . . . . . . . . . . . 9losartan/HCTZ . . . . . . . . . . . . . 9LOTENSIN . . . . . . . . . . . . . . . . . 8LOTENSIN HCT . . . . . . . . . . . . 8LOTREL . . . . . . . . . . . . . . . . . . 10LOTRIMIN AF . . . . . . . . . .20, 60LOTRISONE . . . . . . . . . . . . . . . 20lovastatin . . . . . . . . . . . . . . . . . 11LOVAZA . . . . . . . . . . . . . . . . . . 11LOVENOX . . . . . . . . . . . . . . . . . 7loxapine . . . . . . . . . . . . . . .46, 48loxapine aerosol powder breath

activated . . . . . . . . . . . . . . . 46LOXITANE . . . . . . . . . . . . . . . . 48LOZOL . . . . . . . . . . . . . . . . . . . 11LUDIOMIL . . . . . . . . . . . . . . . . 44lumacaftor/ivacaftor . . . . . . . . 57LUPRON . . . . . . . . . . . . . . . . . . 6LUPRON DEPOT . . . . . . . . . . . 6LUPRON DEPOT 6-MONTH . . 6LUPRON DEPOT-PED . . . . . . . 6lurasidone . . . . . . . . . . . . . . . . 46LURIDE . . . . . . . . . . . . . . . . . . . 54LURIDE LOZI-TABS. . . . . . . . . 54LUVOX . . . . . . . . . . . . . . . .43, 46LUVOX CR . . . . . . . . . . . . . . . . 46LYNPARZA . . . . . . . . . . . . . . . . 7LYRICA . . . . . . . . . . . . . . . . . . . 17LYRICA SOLUTION . . . . . . . . 17LYSODREN . . . . . . . . . . . . . . . . 7LYSTEDA . . . . . . . . . . . . . . . . . 40

MM-CLEAR WC . . . . . . . . . . . . . 49M-M-R II . . . . . . . . . . . . . . . . . . 59MAALOX . . . . . . . . . . . . . .28, 62MAALOX LIQUID . . . . . . . . . . 62macitentan . . . . . . . . . . . . . . . . 12MACROBID . . . . . . . . . . . . . . . 35MACRODANTIN . . . . . . . . . . . 35MAG-OX . . . . . . . . . . . . . . .54, 63MAG64 . . . . . . . . . . . . . . . . . . . 54magnesium chloride. . . . . . . . 54magnesium citrate soln . . . . . 27

75

Index of Covered Drugs

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

magnesium hydroxide susp . 62magnesium oxide . . . . . . .54, 63malathion . . . . . . . . . . . . . . . . . 20MAPAP COLD TAB . . . . . . . . 51maprotiline . . . . . . . . . . . . . . . . 44maraviroc . . . . . . . . . . . . . . . . . 34MARINOL . . . . . . . . . . . . . . . . . 27MARPLAN . . . . . . . . . . . . . . . . 46MATERNA . . . . . . . . . . . . . . . . 56MATULANE . . . . . . . . . . . . . . . . 7MAVIK . . . . . . . . . . . . . . . . . . . . . 8MAVYRET . . . . . . . . . . . . . . . . 32MAXALT/MAXALT MLT . . . . . 15MAXITROL. . . . . . . . . . . . . . . . 40MAXZIDE . . . . . . . . . . . . . . . . . 11measles, mumps & rubella

virus vaccines for inj . . . . . 59mecasermin . . . . . . . . . . . . . . . 26meclizine . . . . . . . . . . . . . .27, 62MEDROL . . . . . . . . . . . . . . . . . 24medroxyprogesterone

acetate . . . . . . . . . . . . .37, 39mefloquine . . . . . . . . . . . . . . . . 35MEGACE . . . . . . . . . . . . . . . . . . 6megestrol acetate . . . . . . . . . . . 6MEKINIST . . . . . . . . . . . . . . . . . 5MELLARIL . . . . . . . . . . . . . . . . 48meloxicam . . . . . . . . . . . . .14, 36melphalan . . . . . . . . . . . . . . . . . 4memantine . . . . . . . . . . . . . . . . 13MENACTRA . . . . . . . . . . . . . . . 59meningococcal (a, c, y, and

w-135) . . . . . . . . . . . . . . . . 59meningococcal (a, c, y, and

w-135) conjugate vaccine . . . . . . . . . . . . . . . . 59

meningococcal (a, c, y, and w-135) oligo conj vac for inj . . . . . . . . . . . . . . . . . . 59

MENOMUNE . . . . . . . . . . . . . . 59MENVEO . . . . . . . . . . . . . . . . . 59meperidine . . . . . . . . . . . . . . . . 14MEPHYTON . . . . . . . . . . . . . . 55MEPRON . . . . . . . . . . . . . . . . . 32mercaptopurine . . . . . . . . . . . . . 4mesalamine . . . . . . . . . . . . . . . 29

mesalamine extended-release . . . . . . . 29

mesalamine supp . . . . . . . . . . 29mesna . . . . . . . . . . . . . . . . . . . . . 5MESNEX . . . . . . . . . . . . . . . . . . 5MESTINON . . . . . . . . . . . . . . . 16MESTINON TIMESPAN . . . . . 16METADATE ER . . . . . . . . . . . . 43METAGLIP . . . . . . . . . . . . . . . . 25METAMUCIL . . . . . . . . . . . . . . 62metaproterenol . . . . . . . . . . . . 53METAPROTERENOL

SYRUP . . . . . . . . . . . . . . . . 53metformin . . . . . . . . . . . . . . . . . 25metformin ER . . . . . . . . . . . . . 25metformin/glyburide . . . . . . . . 25methazolamide . . . . . . . . . . . . 41methenamine . . . . . . . . . . . . . 53methenamine hippurate . . . . . 53METHERGINE . . . . . . . . . .26, 40methimazole . . . . . . . . . . . . . . 26methocarbamol . . . . . . . . . . . . 37methotrexate . . . . . . . . . . . . . . 35methsuximide . . . . . . . . . . . . . 17methyldopa . . . . . . . . . . . . . . . 12methyldopa/HCTZ . . . . . . . . . 12methylene blue . . . . . . . . . . . . 53methylergonovine . . . . . . .26, 40methylphenidate . . . . . . . . . . . 43methylphenidate extended-

release . . . . . . . . . . . . . . . . 43methylphenidate HCL ER

24hr . . . . . . . . . . . . . . . . . . 43methylprednisolone . . . . . . . . 24metipranolol . . . . . . . . . . . . . . . 41metoclopramide . . . . . . . . . . . 27metolazone . . . . . . . . . . . . . . . 11metoprolol . . . . . . . . . . . . . . . . 10metoprolol succinate . . . . . . . 10metreleptin . . . . . . . . . . . . . . . . 46METROCREAM . . . . . . . . . . . 20METROGEL . . . . . . . . . . . .20, 39METROGEL 1% . . . . . . . . . . . 39METROGEL-VAGINAL . . . . . . 39METROLOTION . . . . . . . . . . . 20metronidazole . . . . . . 20, 35, 39

MEVACOR . . . . . . . . . . . . . . . . 11mexiletine . . . . . . . . . . . . . . . . . . 9MEXITIL . . . . . . . . . . . . . . . . . . . 9MIACALCIN . . . . . . . . . . . . . . . 26MICATIN . . . . . . . . . . . . . . .20, 60miconazole . . . . . . . . 20, 39, 60miconazole crm . . . . . . . . . . . 60MICRO-K 10 . . . . . . . . . . . . . . 56MICRONASE . . . . . . . . . . . . . . 25MICROZIDE . . . . . . . . . . . . . . . 11MIDAMOR . . . . . . . . . . . . . . . . 10midodrine . . . . . . . . . . . . . . . . . 12midostaurin . . . . . . . . . . . . . . . . 5mifepristone . . . . . . . . . . . . . . . 26MIGERGOT

SUPPOSITORIES . . . . . . . 15MILK OF MAGNESIA . . . . . . . 62miltefosine . . . . . . . . . . . . . . . . 32MINIPRESS . . . . . . . . . . . . . . . . 9MINOCIN . . . . . . . . . . . . . . . . . 31minocycline . . . . . . . . . . . . . . . 31minoxidil . . . . . . . . . . . . . . . . . . 12MINUTUSS DR SYP . . . . . . . . 50MIRALAX . . . . . . . . . . . . . . . . . 27MIRAPEX . . . . . . . . . . . . . . . . . 16MIRCETTE . . . . . . . . . . . . . . . . 37mirtazapine . . . . . . . . . . . .44, 46mirtazapine ODT . . . . . . . . . . . 46MIRVASO . . . . . . . . . . . . . . . . . 20misoprostol . . . . . . . . . . . . . . . 30MITIGARE . . . . . . . . . . . . . . . . 37mitotane . . . . . . . . . . . . . . . . . . . 7MOBIC . . . . . . . . . . . . . . . .14, 36MODICON . . . . . . . . . . . . . . . . 38MODURETIC . . . . . . . . . . . . . . 10moexipril hcl . . . . . . . . . . . . . . . 8moexipril-hydrochlorothiazide 9mometasone furoate . . . . . . . 19mometasone inhalation . . . . . 52MONISTAT . . . . . . . . . . . . .39, 60MONISTAT 3 . . . . . . . . . . . . . . 39MONISTAT-DERM . . . . . . . . . . 20MONOPRIL . . . . . . . . . . . . . . . . 8MONOPRIL-HCT . . . . . . . . . . . . 8montelukast . . . . . . . . . . . . . . . 53morphine . . . . . . . . . . . . . . . . . 14

76

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

Index of Covered Drugsmorphine extended-release . . 14MOTRIN . . . . . . . . . . . 14, 36, 63MOTRIN IB . . . . . . . . . . . . . . . 63MOVANTIK . . . . . . . . . . . . . . . 30MOZOBIL . . . . . . . . . . . . . . . . . . 7MS CONTIN . . . . . . . . . . . . . . . 14MSIR . . . . . . . . . . . . . . . . . . . . . 14MUCINEX . . . . . . . . . . . . . .49, 50MUCINEX D . . . . . . . . . . . . . . . 50MUCINEX DM . . . . . . . . . . . . . 49MUCOMYST . . . . . . . . . . . . . . 57MULTI SYMPTOM TAB COLD

RLF . . . . . . . . . . . . . . . . . . . 51multiple vitamin . . . . . . . . . . . . 54multivitamins/fluoride/±iron . 55multivitamins/minerals . . . . . . 55mupirocin . . . . . . . . . . . . . . . . . 18MURINE . . . . . . . . . . . . . . . . . . 63MURO 128 . . . . . . . . . . . . . . . 42MYALEPT . . . . . . . . . . . . . . . . . 46MYAMBUTOL . . . . . . . . . . . . . 30MYCELEX . . . . . . . . . . . . .20, 32MYCOBUTIN . . . . . . . . . . . . . . 30mycophenolate mofetil . . . . . . . 6mycophenolate sodium . . . . . . 6MYCOSTATIN . . . . . . . . . .20, 32MYFORTIC. . . . . . . . . . . . . . . . . 6MYLANTA . . . . . . . . . . . . .28, 62MYLANTA LIQUID . . . . . . . . . 62MYLERAN . . . . . . . . . . . . . . . . . 4MYLICON . . . . . . . . . . . . . . . . . 62MYORISAN . . . . . . . . . . . . . . . 18MYSOLINE . . . . . . . . . . . . . . . . 17MYTESI . . . . . . . . . . . . . . . . . . 27

Nnabumetone . . . . . . . . . . . . . . 36nadolol . . . . . . . . . . . . . . . . . . . 10naloxegol . . . . . . . . . . . . . . . . . 30naloxone . . . . . . . . . . . . . . .15, 47NALOXONE INJ . . . . . . . . . . . 47naltrexone . . . . . . . . . . . . .42, 47NAMENDA . . . . . . . . . . . . . . . . 13naphazoline HCL . . . . . . . . . . 40naphazoline/glycerin . . . . . . . 40naphazoline/zinc sulfate . . . . 40

NAPHCON A . . . . . . . . . . . . . . 63NAPROSYN . . . . . . . . . . . .14, 36naproxen . . . . . . . . . . . . . .14, 36naproxen delayed release 14, 36naratriptan . . . . . . . . . . . . . . . . 15NARCAN NASAL SPRAY . . . 47NARDIL . . . . . . . . . . . . . . . . . . 46NASACORT ALLERGY 24

HOUR . . . . . . . . . . . . . . . . . 23nasal sprays . . . . . . . . . . . . . . . 61NASALCROM . . . . . . . . . . . . . 23NATALCARE . . . . . . . . . . .55, 56nateglinide . . . . . . . . . . . . . . . . 25NATROBA . . . . . . . . . . . . . . . . 20NAVANE . . . . . . . . . . . . . . . . . . 48NEBUPENT . . . . . . . . . . . . . . . 32NEBUSAL . . . . . . . . . . . . . . . . 57nefazodone hcl . . . . . . . . . . . . 44nelfinavir . . . . . . . . . . . . . . . . . . 34NEO-SYNEPHRINE . . . . .23, 61neomycin sulfate . . . . . . . . . . . 35neomycin/bacitracin/

polymyxin . . . . . . . . . . . . . . 42neomycin/polymyxin B/

bacitracin . . . . . . . . . . . . . . 18neomycin/polymyxin B/

dexamethasone . . . . . . . . 40neomycin/polymyxin B/

gramicidin . . . . . . . . . . . . . 42neomycin/polymyxin B/

hydrocortisone . . . . . .22, 40NEORAL . . . . . . . . . . . . . . . . . . 6NEOSPORIN . . . . . . . 18, 42, 61NEPHROCAPS . . . . . . . . . . . . 56NEPTAZANE . . . . . . . . . . . . . . 41NESINA . . . . . . . . . . . . . . . . . . 25NESTABSCBF/FA/RX . . . . . . 56NEULASTA . . . . . . . . . . . . . . . . 7NEUMEGA . . . . . . . . . . . . . . . . . 7NEURONTIN . . . . . . . . . . . . . . 17NEUTROGENA OIL FREE

ACNE WASH . . . . . . . . . . . 18nevirapine . . . . . . . . . . . . . . . . 34nevirapine ER . . . . . . . . . . . . . 34NEXAVAR . . . . . . . . . . . . . . . . . 5NEXIUM 24HR OTC . . . . . . . . 28

NEXIUM DELAYED RELEASE PACKET . . . . . . . . . . . . . . . 28

niacin . . . . . . . . . . . . . . . . . . . . 11niacin extended-release . . . . . 11NIACINOL . . . . . . . . . . . . . . . . 11NIACOR . . . . . . . . . . . . . . . . . . 11NIASPAN . . . . . . . . . . . . . . . . . 11nicardipine . . . . . . . . . . . . . . . . 10NICODERM CQ . . . . . . . .48, 63NICORETTE OTC . . . . . . . . . . 48nicotine . . . . . . . . . . . . . . . .48, 63NICOTINE GUM . . . . . . . . . . . 63nicotine inhaler system . . . . . 48nicotine nasal spray . . . . . . . . 48nicotine polacrilex gum . . . . . 48nicotine polacrilex lozenge . . 48NICOTROL INHALER. . . . . . . 48NICOTROL NASAL SPRAY . . 48nifedipine . . . . . . . . . . . . . . . . . 10nifedipine extended-release . 10NIFEREX . . . . . . . . . . 54, 55, 63NIFEREX-PN FORTE . . . . . . . 56nilotinib . . . . . . . . . . . . . . . . . . . . 5nimodipine . . . . . . . . . . . . . . . . 10nimodipine oral soln . . . . . . . . 10NIMOTOP. . . . . . . . . . . . . . . . . 10NINLARO . . . . . . . . . . . . . . . . . . 5nintedanib . . . . . . . . . . . . . . . . 57niraparib . . . . . . . . . . . . . . . . . . . 7nitazoxanide suspension . . . . 32nitisinone . . . . . . . . . . . . . . . . . 26NITREK . . . . . . . . . . . . . . . . . . 12NITRO-BID . . . . . . . . . . . . . . . . 12NITRO-DUR . . . . . . . . . . . . . . . 12nitrofurantoin

extended-release . . . . . . . 35nitrofurantoin macrocrystals . 35nitrofurantoin susp . . . . . . . . . 35nitroglycerin . . . . . . . . . . . .12, 21NITROLINGUAL . . . . . . . . . . . 12NITROSTAT . . . . . . . . . . . . . . . 12NITYR . . . . . . . . . . . . . . . . . . . . 26NIX 20, 62NIX CREME RINSE . . . . . . . . . 20NIZORAL . . . . . . . . . . 20, 21, 32NIZORAL SHAMPOO. . . . . . . 21

77

Index of Covered Drugs

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

NOLVADEX . . . . . . . . . . . . . . . . 5NORCO . . . . . . . . . . . . . . . . . . 14NORDETTE . . . . . . . . . . . . . . . 38norelgestromin/EE . . . . . . . . . 38norethindrone . . . . . . . . . . 37-39norethindrone acetate . . . 37-39norethindrone acetate/

EE . . . . . . . . . . . . . . . . .37, 38norethindrone acetate/

EE/iron . . . . . . . . . . . . . . . . 38norethindrone/EE . . . . . . .37, 38norethindrone/ME . . . . . . . . . 38NORFLEX . . . . . . . . . . . . . . . . 37norgestimate/EE . . . . . . . . . . . 38norgestrel/EE . . . . . . . . . . . . . 38NORPACE . . . . . . . . . . . . . . . . . 9NORPACE CR . . . . . . . . . . . . . . 9NORPRAMIN . . . . . . . . . . . . . . 44nortriptyline . . . . . . . . . . . . . . . 44NORVASC . . . . . . . . . . . . . . . . 10NORVIR . . . . . . . . . . . . . . . . . . 34NOVAREL . . . . . . . . . . . . . . . . 39NOVOLIN . . . . . . . . . . 24, 25, 61NOVOLIN 70/30 . . . . . . . . . . . 25NOVOLIN N . . . . . . . . . . . . . . . 24NOVOLIN R . . . . . . . . . . . . . . . 24NOVOLOG MIX 70/30 . . . . . . 24NUEDEXTA . . . . . . . . . . . . . . . 47NULYTELY . . . . . . . . . . . . . . . . 27NUPLAZID . . . . . . . . . . . . . . . . 46NUVARING . . . . . . . . . . . . . . . 37NUVIGIL . . . . . . . . . . . . . . . . . . 13NYMALIZE . . . . . . . . . . . . . . . . 10nystatin . . . . . . . . . . . . . . . .20, 32NYTOL QUICK CAPS . . . . . . . 45

OOCEAN NASAL SPRAY . . . . . 23octreotide . . . . . . . . . . . . . . . . . . 7OCUFEN . . . . . . . . . . . . . . . . . 40OCUFLOX . . . . . . . . . . . . . . . . 42ODEFSEY. . . . . . . . . . . . . . . . . 33ODOMZO . . . . . . . . . . . . . . . . . . 7OFEV . . . . . . . . . . . . . . . . . . . . 57ofloxacin . . . . . . . . . . . 22, 31, 42OGEN . . . . . . . . . . . . . . . . . . . . 39

olanzapine . . . . . . . . . . . . .46, 47olanzapine for IM inj . . . . . . . . 46olanzapine ODT . . . . . . . . . . . 46olanzapine pamoate for

extended rel IM sus . . . . . 46olanzapine-fluoxetine . . . . . . . 46olaparib . . . . . . . . . . . . . . . . . . . 7olodaterol . . . . . . . . . . . . . . . . . 52olsalazine sodium . . . . . . . . . . 29omalizumab . . . . . . . . . . . . . . . 52omega 3 acid ethyl esters . . . 11omeprazole delayed-release . 28OMNICEF . . . . . . . . . . . . . . . . . 31ondansetron . . . . . . . . . . . . . . 27One Touch Systems . . . . . . . . 25One Touch Test Strips . . . . . . 25ONFI . . . . . . . . . . . . . . . . . . . . . 16oprelvekin . . . . . . . . . . . . . . . . . 7OPSUMIT . . . . . . . . . . . . . . . . . 12OPTIPRANOLOL . . . . . . . . . . 41OPTIVAR . . . . . . . . . . . . . . . . . 40ORAP . . . . . . . . . . . . . . . . . . . . 48ORAPRED . . . . . . . . . . . . . . . . 24ORKAMBI . . . . . . . . . . . . . . . . 57orphenadrine

extended-release . . . . . . . 37ORTHO COIL . . . . . . . . . . . . . 37ortho diaphragm . . . . . . . . . . . 37ORTHO EVRA . . . . . . . . . . . . . 38ORTHO FLAT . . . . . . . . . . . . . 37ORTHO FLEX . . . . . . . . . . . . . 37ORTHO MICRONOR . . . . . . . 38ORTHO TRI-CYCLEN . . . . . . . 38ORTHO-CEPT . . . . . . . . . . . . . 38ORTHO-CYCLEN . . . . . . . . . . 38ORTHO-NOVUM 1/35 . . . . . . 38ORTHO-NOVUM 1/50 . . . . . . 38ORTHO-NOVUM 10/11 . . . . 37ORTHO-NOVUM 7/7/7 . . . . . 38ORUDIS . . . . . . . . . . . . . . .14, 36OS-CAL . . . . . . . . . . . . . . .54, 63oseltamivir . . . . . . . . . . . . . . . . 33OSENI . . . . . . . . . . . . . . . . . . . . 25OTEZLA . . . . . . . . . . . . . . . . . . 35OVCON 50 . . . . . . . . . . . . . . . . 38OVIDE . . . . . . . . . . . . . . . . . . . . 20

OVIDREL . . . . . . . . . . . . . . . . . 39OVRAL . . . . . . . . . . . . . . . . . . . 38oxaprozin . . . . . . . . . . . . . .14, 36oxazepam . . . . . . . . . . . . . . . . 43oxcarbazepine . . . . . . . . . . . . . 17oxybutynin chloride . . . . . . . . 53oxybutynin IR . . . . . . . . . . . . . . 53oxybutynin patch. . . . . . . .54, 63oxycodone . . . . . . . . . . . . .14, 15oxycodone/acetaminophen . 15oxycodone/aspirin . . . . . . . . . 15OXYFAST . . . . . . . . . . . . . . . . . 14oxymetazoline . . . . . . . . . . . . . 23oxymorphone ER . . . . . . . . . . 15OXYTROL FOR WOMEN OTC

PATCH . . . . . . . . . . . . .54, 63

Ppalbociclib . . . . . . . . . . . . . . . . . 5paliperidone . . . . . . . . . . . .46, 47paliperidone tab SR 24HR . . 46palivizumab . . . . . . . . . . . . . . . 35PAMELOR . . . . . . . . . . . . . . . . 44pancrelipase . . . . . . . . . . . . . . 29panobinostat . . . . . . . . . . . . . . . 4PANRETIN . . . . . . . . . . . . . . . . . 6pantoprazole . . . . . . . . . . . . . . 28PARAFON FORTE DSC . . . . . 37PARNATE . . . . . . . . . . . . . . . . . 44paromomycin . . . . . . . . . . . . . 35paroxetine . . . . . . . . . . . . .44, 46paroxetine HCL tab SR

24HR . . . . . . . . . . . . . . . . . 46paroxetine mesylate tab . . . . . 46PASER . . . . . . . . . . . . . . . . . . . 30pasireotide . . . . . . . . . . . . . . . . . 7patiromer . . . . . . . . . . . . . . . . . 12PAXIL . . . . . . . . . . . . . . . . .44, 46PAXIL CR . . . . . . . . . . . . . . . . . 46pazopanib . . . . . . . . . . . . . . . . . 5PEDIACARE LIQ MULTI-SY . . 51PEDIALYTE . . . . . . . . . . . .54, 62PEDIAPRED . . . . . . . . . . . . . . . 24PEDIAZOLE . . . . . . . . . . . . . . . 31peg 3350/electrolytes . . . . . . 27

78

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

Index of Covered Drugspeg 3350/sodium bicarbonate/

sodium chloride . . . . . . . . 27peg 3350/sodium bicarbonate/

sodium chloride/potassium chloride . . . . . . . . . . . . . . . 27

PEGASYS . . . . . . . . . . . . . . . . . 32PEGASYS PROCLICK . . . . . . 32pegfilgrastim . . . . . . . . . . . . . . . 7peginterferon alfa-2a . . . . . . . 32peginterferon alfa-2b . . . . . . . . 6peginterferon beta-1a . . . . . . . 16pegvisomant . . . . . . . . . . . . . . 26penicillamine . . . . . . . . . . . . . . 35penicillin VK . . . . . . . . . . . . . . . 31PENLAC SOLUTION 8% . . . . 20pentamidine isethionate for

nebulization . . . . . . . . . . . . 32pentazocine/naloxone . . . . . . 15pentosan polysulfate sodium 54pentoxifylline

extended-release . . . . . . . . 8PEPCID . . . . . . . . . . . . . . .28, 62PEPCID AC . . . . . . . . . . . .28, 62PERCOCET . . . . . . . . . . . . . . . 15PERCODAN . . . . . . . . . . . . . . . 15PERIDEX . . . . . . . . . . . . . . . . . 23perindopril erbumine . . . . . . . . 8permethrin . . . . . . . . . . . . .20, 62perphenazine . . . . . . . . . .44, 48PERSANTINE . . . . . . . . . . . . . . 8PEXEVA . . . . . . . . . . . . . . . . . . 46phenazopyridine . . . . . . . . . . . 54phenelzine . . . . . . . . . . . . . . . . 46PHENERGAN . . . . . . . . . .27, 50PHENERGAN DM . . . . . . . . . . 50phenobarbital . . . . . . . . . . . . . 17phenyl salicylate . . . . . . . . . . . 53phenylephrine . . . . . . . 23, 48-51phenylephrine/

brompheniramine/dextromethorphan . . . . . . 50

phenylephrine/chlorpheniramine/ dextromethorphan . . .50, 51

phenylephrine/chlorpheniramine/dihydrocodeine . . . . . . . . . 51

phenylephrine/dextromethorphan . . . . . . 51

phenylephrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 51

phenylephrine/ephed/CPM w/carbetapentane . . . . . . . . 51

phenylephrine/guaifenesin . . 51phenylephrine/pyrilamine w/

hydrocodone . . . . . . . . . . . 51PHENYLHIST LIQ DH . . . . . . 49PHENYTEK . . . . . . . . . . . . . . . 17phenytoin . . . . . . . . . . . . . . . . . 17phenytoin sodium extended . 17PHILLIPS COLON

HEALTH . . . . . . . . . . . .29, 62PHOS-FLUR . . . . . . . . . . .54, 63PHOSPHOLINE IODINE . . . . 41phosphorus . . . . . . . . . . . . . . . 56PHRENILIN . . . . . . . . . . . . . . . 13phytonadione. . . . . . . . . . . . . . 55pilocarpine . . . . . . . . . . . . .23, 41PILOPINE HS GEL . . . . . . . . . 41pimavanserin . . . . . . . . . . . . . . 46pimecrolimus . . . . . . . . . . . . . . 21pimozide . . . . . . . . . . . . . . . . . 48PIN-X . . . . . . . . . . . . . . . . . . . . . 30pioglitazone . . . . . . . . . . . . . . . 25pirfenidone capsule . . . . . . . . 57piroxicam . . . . . . . . . . . . . .14, 36PLAN B ONE STEP . . . . . . . . 37PLAQUENIL . . . . . . . . . . . . . . . 35PLAVIX . . . . . . . . . . . . . . . . . . . . 8PLEGRIDY . . . . . . . . . . . . . . . . 16PLENDIL . . . . . . . . . . . . . . . . . 10plerixafor . . . . . . . . . . . . . . . . . . 7PLETAL . . . . . . . . . . . . . . . . . . . 8PLEXION . . . . . . . . . . . . . . . . . 18pneumococcal 13-valent

conjugate . . . . . . . . . . . . . . 59pneumococcal vaccine

polyvalent. . . . . . . . . . . . . . 59PNEUMOVAX . . . . . . . . . . . . . 59

PNEUMOVAX 23 . . . . . . . . . . 59podofilox . . . . . . . . . . . . . . . . . 20POLY-VI-FLOR . . . . . . . . . . . . . 55POLY-VI-SOL . . . . . . . . . . . . . . 63polyethylene glycol 3350 . . . . 27polymyxin B/bacitracin . .18, 42polymyxin B/trimethoprim . . . 42polysaccharide iron caps . . . . 63polysaccharide iron complex 55POLYSPORIN . . . . . . . . . . . . . 42POLYTRIM . . . . . . . . . . . . . . . . 42pomalidomide . . . . . . . . . . . . . . 6POMALYST . . . . . . . . . . . . . . . . 6ponatinib . . . . . . . . . . . . . . . . . . 5potassium acid phosphate . . 56potassium bicarbonate/

potassium citrate effervescent . . . . . . . . . . . . 56

potassium chloride . . . . . .27, 56potassium chloride ext-rel . . . 56potassium chloride extended-

release . . . . . . . . . . . . . . . . 56potassium citrate . . . . . . . .54, 56potassium iodide . . . . . . . . . . 51POTIGA . . . . . . . . . . . . . . . . . . 16povidone-iodine . . . . . . . . . . . 35PRALUENT . . . . . . . . . . . . . . . 11pramipexole . . . . . . . . . . . . . . . 16pramlintide . . . . . . . . . . . . . . . . 26PRAMLYTE . . . . . . . . . . . . . . . 46PRANDIN . . . . . . . . . . . . . . . . . 25prasugrel . . . . . . . . . . . . . . . . . . 8praziquantel . . . . . . . . . . . . . . . 30prazosin . . . . . . . . . . . . . . . . . . . 9PRECOSE . . . . . . . . . . . . . . . . 25PRED FORTE . . . . . . . . . . . . . 41PRED MILD . . . . . . . . . . . . . . . 41PRED-G . . . . . . . . . . . . . . . . . . 40prednicarbate . . . . . . . . . . . . . 19prednisolone . . . . . . . 24, 40, 41prednisolone acetate . . . .40, 41prednisolone phosphate . . . . 41prednisolone sodium

phosphate . . . . . . . . . . . . . 24prednisone . . . . . . . . . . . . . . . . 24pregabalin . . . . . . . . . . . . . . . . 17

79

Index of Covered Drugs

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

PRELONE . . . . . . . . . . . . . . . . 24PREMARIN . . . . . . . . . . . . . . . 39PREMPHASE . . . . . . . . . . . . . 39PREMPRO . . . . . . . . . . . . . . . . 39prenat w/o A w/fecbn-fegl-DSS-

FA & DHA . . . . . . . . . . . . . . 55prenat-FE Bis-FE prot succ-FA-

CA & omega 3 . . . . . . . . . 55prenat-FE bis-FE prot succ-FA-

CA & omega DR . . . . . . . . 55prenatal vit w/FE bisglycinate

chelate-FA . . . . . . . . . . . . . 55prenatal vit w/FE polysac cmplx-

FA . . . . . . . . . . . . . . . . . . . . 55prenatal vit w/iron carbonyl-

FA . . . . . . . . . . . . . . . . . . . . 55PRENATAL VITAMINS W/

FOLIC ACID . . . . . . . . . . . . 56prenatal vitamins w/folic acid 56prenatal w/o A w/FE carbonyl-

FE gluc-DSS-FA . . . . . . . . 56PREPARATION H . . . . . . . . . . 62PREVACID . . . . . . . . . . . . . . . . 28PREVACID SOLUTAB . . . . . . 28PREVIDENT . . . . . . . . . . . . . . . 54PREVNAR 13 . . . . . . . . . . . . . 59PREZCOBIX . . . . . . . . . . . . . . 34PREZISTA . . . . . . . . . . . . . . . . 34PRIFTIN . . . . . . . . . . . . . . . . . . 30PRILOSEC . . . . . . . . . . . . . . . . 28primaquine. . . . . . . . . . . . . . . . 35primidone . . . . . . . . . . . . . . . . . 17PRINCIPEN . . . . . . . . . . . . . . . 31PRISTIQ . . . . . . . . . . . . . . . . . . 45PROAMATINE . . . . . . . . . . . . . 12probenecid . . . . . . . . . . . . . . . 37probiotics . . . . . . . . . . . . . .29, 62procarbazine . . . . . . . . . . . . . . . 7PROCARDIA . . . . . . . . . . . . . . 10PROCARDIA XL . . . . . . . . . . . 10prochlorperazine . . . . . . . . . . . 27PROCRIT . . . . . . . . . . . . . . . . . . 7PROCTOSOL HC CREAM

2.5% . . . . . . . . . . . . . . . . . . 21PROCTOZONE CREAM-HC

2.5% . . . . . . . . . . . . . . . . . . 21

progesterone inj . . . . . . . . . . . 39progesterone

micronized . . . . . . . . . .38, 39progesterone micronized

cap . . . . . . . . . . . . . . . . . . . 38PROGRAF . . . . . . . . . . . . . . . . . 6PROLIXIN . . . . . . . . . . . . . . . . . 48PROLIXIN DECANOATE . . . . 48PROMACTA . . . . . . . . . . . . . . . 57PROMETH VC SYP

6.25-5/5 . . . . . . . . . . . . . . . 51promethazine . . . . . . . 27, 49-51promethazine &

phenylephrine . . . . . . .49, 51PROMETHAZINE SYP DM . . 50PROMETHAZINE VC

W/CODEINE . . . . . . . . . . . 49PROMETHAZINE

W/CODEINE . . . . . . . . . . . 49PROMETRIUM . . . . . . . . .38, 39propafenone . . . . . . . . . . . . . . . 9propantheline . . . . . . . . . . . . . 54propranolol . . . . . . . . . . . .10, 15propranolol ER 24hr . . . . . . . . 10propranolol/HCTZ . . . . . . . . . 10propylthiouracil . . . . . . . . . . . . 26PROSCAR . . . . . . . . . . . . . . . . 53PROSOM . . . . . . . . . . . . . . . . . 45PROTONIX . . . . . . . . . . . . . . . . 28PROTOPIC 0.03% . . . . . . . . . 21PROTOPIC 0.1% . . . . . . . . . . . 21protriptyline . . . . . . . . . . . . . . . 46PROVENTIL . . . . . . . . . . . . . . . 52PROVERA . . . . . . . . . . . . . . . . 39PROZAC . . . . . . . . . . . . . .44, 46PROZAC WEEKLY . . . . . . . . . 46PRUET DHA PAK SETONET

PAK . . . . . . . . . . . . . . . . . . . 55PRUET DHAEC PAK . . . . . . . 55PSE/GG . . . . . . . . . . . . . . . . . . 50pseudoephedrine tan/

dexchlorphen tan/DM tan 52pseudoephedrine/

acetaminophen/dextromethorphan . . . . . . 51

pseudoephedrine/chlorpheniramine/dextromethorphan . . . . . . 51

pseudoephedrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 51

pseudoephedrine/iburprofen 51psyllium . . . . . . . . . . . . . . . . . . 62PULMICORT RESPULES . . . 52PULMOZYME . . . . . . . . . . . . . 57PURINETHOL . . . . . . . . . . . . . . 4pyrantel pamoate . . . . . . . . . . 30pyrazinamide . . . . . . . . . . . . . . 30pyrethrins/piperonyl butoxide

shampoo . . . . . . . . . . .20, 62PYRIDIUM . . . . . . . . . . . . . . . . 54pyridostigmine . . . . . . . . . . . . . 16pyridostigmine

extended-release . . . . . . . 16pyrilamine tan/phenyleph

tan . . . . . . . . . . . . . . . . . . . . 52pyrimethamine . . . . . . . . . . . . 35

QQUESTRAN . . . . . . . . . . . . . . . 11QUESTRAN-LIGHT . . . . . . . . . 11quetiapine . . . . . . . . . . . . .46, 47quetiapine fumarate tab SR

24HR . . . . . . . . . . . . . . . . . 46quinapril . . . . . . . . . . . . . . . . . 8, 9quinapril/hydrochlorothiazide . 9QUINIDINE GLUCONATE

EXT-REL . . . . . . . . . . . . . . . 9quinidine gluconate

extended-release . . . . . . . . 9quinidine sulfate . . . . . . . . . . . . 9QUINIDINE SULFATE

EXT-REL . . . . . . . . . . . . . . . 9quinidine sulfate extended-

release . . . . . . . . . . . . . . . . . 9QVAR REDIHALER . . . . . . . . . 52

RR-TANNAMINE . . . . . . . . . . . . 48raloxifene . . . . . . . . . . . . . . . . . 26raltegravir . . . . . . . . . . . . . . . . . 33

80

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

Index of Covered Drugsraltegravir susp . . . . . . . . . . . . 33ramipril . . . . . . . . . . . . . . . . . . . . 8RANEXA . . . . . . . . . . . . . . . . . 12ranitidine . . . . . . . . . . . . . . . . . 28ranitidine syrup . . . . . . . . . . . . 28ranolazine . . . . . . . . . . . . . . . . 12RAPAMUNE. . . . . . . . . . . . . . . . 6RAVICTI . . . . . . . . . . . . . . . . . . 58RAZADYNE . . . . . . . . . . . . . . . 13REBETOL . . . . . . . . . . . . . . . . 32RECOMBIVAX HB . . . . . . . . . 58rectal crm, suppositories . . . . 62RECTIV . . . . . . . . . . . . . . . . . . . 21REESE’S PINWORM

MEDICINE . . . . . . . . . . . . . 30REGLAN . . . . . . . . . . . . . . . . . 27regorafenib . . . . . . . . . . . . . . . . 5REGRANEX . . . . . . . . . . . . . . . 21RELAFEN . . . . . . . . . . . . . . . . . 36RELENZA. . . . . . . . . . . . . . . . . 33RELION 70/30 . . . . . . . . . . . . 25RELION N . . . . . . . . . . . . . . . . 24RELION R . . . . . . . . . . . . . . . . 24REMERON . . . . . . . . . . . . .44, 46REMERON SOLTAB . . . . . . . . 46RENVELA . . . . . . . . . . . . . . . . 57repaglinide . . . . . . . . . . . . . . . . 25REQUIP . . . . . . . . . . . . . . . . . . 16RESCRIPTOR . . . . . . . . . . . . . 34RESTORIL . . . . . . . . . . . . . . . . 45RETIN-A . . . . . . . . . . . . . . . . . . 18RETROVIR . . . . . . . . . . . . . . . . 33REVATIO . . . . . . . . . . . . . . . . . 12REVATIO SUSPENSION . . . . 12REVIA . . . . . . . . . . . . . . . . .42, 47REVLIMID . . . . . . . . . . . . . . . . . 6REXULTI . . . . . . . . . . . . . . . . . . 45REYATAZ . . . . . . . . . . . . . . . . . 34REYATAZ POWDER

PACKET . . . . . . . . . . . . . . . 34ribavirin . . . . . . . . . . . . . . . . . . . 32RID SHAMPOO . . . . . . . . .20, 62RIDAURA . . . . . . . . . . . . . . . . . 35rifabutin . . . . . . . . . . . . . . . . . . 30RIFADIN . . . . . . . . . . . . . . . . . . 30rifapentine . . . . . . . . . . . . . . . . 30

rifapin . . . . . . . . . . . . . . . . . . . . 30rilpivirine . . . . . . . . . . . . . . .33, 34RILUTEK . . . . . . . . . . . . . . . . . 13riluzole . . . . . . . . . . . . . . . . . . . 13rimantadine . . . . . . . . . . . . . . . 33rimexolone . . . . . . . . . . . . . . . . 41riociguat . . . . . . . . . . . . . . . . . . 12RISA-BID . . . . . . . . . . . . . .29, 62RISAQUAD . . . . . . . . . . . . .29, 62RISPERDAL . . . . . . . . . . . .46, 47RISPERDAL CONSTA . . .46, 47RISPERDAL M-TAB . . . . . . . . 46RISPERDAL SOLUTION . . . . 47risperidone . . . . . . . . . . . . .46, 47risperidone microspheres

for inj . . . . . . . . . . . . . . . . . . 46risperidone ODT . . . . . . . . . . . 46risperidone oral soln . . . . . . . . 47RITALIN . . . . . . . . . . . . . . . . . . 43RITALIN LA . . . . . . . . . . . . . . . 43ritonavir . . . . . . . . . . . . . . . . . . . 34rivaroxaban . . . . . . . . . . . . . . . . 7rivastigmine . . . . . . . . . . . . . . . 13rizatriptan . . . . . . . . . . . . . . . . . 15RMS . . . . . . . . . . . . . . . . . . . . . 14ROBAXIN . . . . . . . . . . . . . . . . . 37ROBINUL . . . . . . . . . . . . . . . . . 28ROBITUSSIN . . . . . . . . 49-51, 61ROBITUSSIN CF . . . . . . . .50, 61ROBITUSSIN DM . . . . . . .49, 61ROBITUSSIN LIQ

CGH/ALRG . . . . . . . . . . . . 51ROBITUSSIN LIQ

CGH/CLD . . . . . . . . . .49, 51ROBITUSSIN LIQ

CGH/CONG . . . . . . . . . . . 50ROBITUSSIN LIQ

HD/CHST . . . . . . . . . . . . . 51ROBITUSSIN LIQ

PED NGHT . . . . . . . . . . . . 51ROBITUSSIN PE . . . . . . . .50, 61ROBITUSSIN PED LIQ CGH/

COLD . . . . . . . . . . . . . . . . . 49ROBITUSSIN PED SYP . . . . . 50ROBITUSSIN SYP

CHST CNG . . . . . . . . . . . . 50

ROBITUSSIN SYP MAX-ST . . 50ROCALTROL . . . . . . . . . . . . . . 54ROCALTROL SOLUTION . . . 54rolapitant . . . . . . . . . . . . . . . . . 28RONDEC DM . . . . . . . . . .50, 51RONDEC DM DROPS . . . . . . 51RONDEC DROPS . . . . . . . . . . 49RONDEC SYRUP . . . . . . . . . . 49ropinirole . . . . . . . . . . . . . . . . . 16ROWASA . . . . . . . . . . . . . . . . . 29ROXICODONE . . . . . . . . . . . . 15RUBRACA . . . . . . . . . . . . . . . . . 7rucaparib . . . . . . . . . . . . . . . . . . 7rufinamide . . . . . . . . . . . . . . . . 17ruxolitinib . . . . . . . . . . . . . . . . . . 5RYDAPT . . . . . . . . . . . . . . . . . . . 5RYNA-12 S . . . . . . . . . . . . . . . 52RYNATAN PEDIATRIC SUSP 49RYNATUSS PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 51RYTHMOL . . . . . . . . . . . . . . . . . 9

SSABRIL SOLUTION . . . . . . . . 17sacubitril/valsartan . . . . . . . . . . 9SAL-TROPINE . . . . . . . . . . . . . 30SALAC . . . . . . . . . . . . . . . . . . . 60SALAGEN . . . . . . . . . . . . . . . . 23salicylic acid . . . . 18, 20, 60, 63salicylic acid 17%/

collodion . . . . . . . . . . .20, 63salicylic acid lotion 2% . . . . . . 60saline nasal spray 0.65% . . . . 23salsalate . . . . . . . . . . . . . . . . . . 36SANCTURA . . . . . . . . . . . . . . . 54SANDIMMUNE . . . . . . . . . . . . . 6SANDOSTATIN . . . . . . . . . . . . . 7SANTYL . . . . . . . . . . . . . . . . . . 21SAPHRIS . . . . . . . . . . . . . . . . . 45sapropterin . . . . . . . . . . . . . . . . 26sapropterin powder . . . . . . . . 26saquinavir mesylate . . . . . . . . 34sargramostim. . . . . . . . . . . . . . . 7sarilumab . . . . . . . . . . . . . . . . . 35SAVAYSA . . . . . . . . . . . . . . . . . . 7SCALPICIN . . . . . . . . . . . . . . . 20

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scopolamine . . . . . . . . . . . . . . 41SEASONALE . . . . . . . . . . . . . . 37SECTRAL . . . . . . . . . . . . . . . . . . 9secukinumab . . . . . . . . . . . . . . 36SEGLUROMET . . . . . . . . . . . . 25selegiline . . . . . . . . . . . . . .16, 47selegiline td patch . . . . . . . . . . 47selenium sulfide . . . . . . . . . . . 21SELSUN . . . . . . . . . . . . . . . . . . 21SELZENTRY . . . . . . . . . . . . . . 34sennosides . . . . . . . . . . . . . . . 27SENOKOT . . . . . . . . . . . . . . . . 27SENSIPAR . . . . . . . . . . . . . . . . 57SERAX . . . . . . . . . . . . . . . . . . . 43SEROMYCIN . . . . . . . . . . . . . . 30SEROQUEL . . . . . . . . . . . .46, 47SEROQUEL XR . . . . . . . . . . . . 46sertraline . . . . . . . . . . . . . . . . . 44SERZONE . . . . . . . . . . . . . . . . 44sevelamer . . . . . . . . . . . . . . . . . 57SIGNIFOR . . . . . . . . . . . . . . . . . 7sildenafil . . . . . . . . . . . . . . . . . . 12SILVADENE . . . . . . . . . . . . . . . 18silver sulfadiazine . . . . . . . . . . 18simethicone . . . . . . . . . . . .28, 62simvastatin . . . . . . . . . . . . . . . . 11SINEMET . . . . . . . . . . . . . . . . . 16SINEMET CR . . . . . . . . . . . . . . 16SINEQUAN . . . . . . . . . . . . . . . 44SINGULAIR . . . . . . . . . . . . . . . 53sirolimus . . . . . . . . . . . . . . . . . . . 6SIRTURO . . . . . . . . . . . . . . . . . 35sodium chloride for

nebulizer . . . . . . . . . . . . . . 57sodium chloride hypertonic . 42sodium chloride hypertonic

ophth soln . . . . . . . . . . . . . 42sodium chloride irrigation soln

0.9% . . . . . . . . . . . . . . . . . . 59sodium citrate/citric acid . . . . 54sodium phenylbutyrate . . . . . 58sodium phosphate

monobasic . . . . . . . . . . . . . 53sodium polystyrene sulfonate 12SOLIQUA . . . . . . . . . . . . . . . . . 24somatropin . . . . . . . . . . . . . . . . 26

SOMAVERT . . . . . . . . . . . . . . . 26SONATA . . . . . . . . . . . . . . . . . . 45sonidegib . . . . . . . . . . . . . . . . . . 7sorafenib . . . . . . . . . . . . . . . . . . 5SORIATANE . . . . . . . . . . . . . . . 20sotalol . . . . . . . . . . . . . . . . . . . . 10sotalol AF . . . . . . . . . . . . . . . . . 10spacers . . . . . . . . . . . . . . . . . . . 57spinosad . . . . . . . . . . . . . . . . . 20spironolactone. . . . . . . . . . . . . 11spironolactone/

hydrochlorothiazide . . . . . 11SPORANOX . . . . . . . . . . . . . . . 32SPRYCEL . . . . . . . . . . . . . . . . . . 4SSKI . . . . . . . . . . . . . . . . . . . . . 51STADOL . . . . . . . . . . . . . . . . . . 14STARLIX . . . . . . . . . . . . . . . . . . 25STATUSS DM SYP . . . . . . . . . 50stavudine . . . . . . . . . . . . . . . . . 33STEGLATRO . . . . . . . . . . . . . . 25STELAZINE . . . . . . . . . . . . . . . 48STIOLTO RESPIMAT . . . . . . . 52STIVARGA . . . . . . . . . . . . . . . . . 5stool softeners . . . . . . . . . . . . . 62STRENSIQ . . . . . . . . . . . . . . . . 26STRIBILD . . . . . . . . . . . . . . . . . 34STRIVERDI RESPIMAT . . . . . 52STROMECTOL . . . . . . . . . . . . 30STUART PRENATAL . . . . . . . 63SUBOXONE . . . . . . . . . . . . . . . 47SUBUTEX . . . . . . . . . . . . . . . . 47succimer . . . . . . . . . . . . . . . . . 57sucralfate . . . . . . . . . . . . . . . . . 28sugar+orthophosphoric acid 62sulcralfate . . . . . . . . . . . . . . . . . 28SULFACET-R . . . . . . . . . . . . . . 18sulfacetamide . . . . . . 18, 40, 42sulfacetamide sodium lotion . 18sulfacetamide/pred phos . . . 40sulfacetamide/sulfur . . . . . . . . 18sulfamethoxazole/

trimethoprim, DS . . . . . . . 31sulfasalazine . . . . . . . . . . .29, 36sulfasalazine

delayed-release . . . . . .29, 36sulindac . . . . . . . . . . . . . . .14, 36

sumatriptan . . . . . . . . . . . . . . . 15sumatriptan-naproxen . . . . . . 15SUMYCIN . . . . . . . . . . . . . . . . . 31sunitinib . . . . . . . . . . . . . . . . . . . 5SUPRAX . . . . . . . . . . . . . . . . . . 31SURMONTIL . . . . . . . . . . . . . . 47SUSTIVA . . . . . . . . . . . . . . . . . . 34SUTENT . . . . . . . . . . . . . . . . . . . 5SYLATRON . . . . . . . . . . . . . . . . 6SYMBYAX . . . . . . . . . . . . . . . . 46SYMLINPEN 60 . . . . . . . . . . . 26SYMMETREL . . . . . . . . . .16, 33SYNAGIS . . . . . . . . . . . . . . . . . 35SYNALAR . . . . . . . . . . . . . . . . 19SYNTHROID . . . . . . . . . . . . . . 26

TT-STAT . . . . . . . . . . . . . . . . . . . 18tabloid . . . . . . . . . . . . . . . . . . . . . 4tacrolimus . . . . . . . . . . . . . . 6, 21TAFINLAR . . . . . . . . . . . . . . . . . 4TAGAMET . . . . . . . . . . . . . . . . 28TALWIN NX . . . . . . . . . . . . . . . 15TAMBOCOR . . . . . . . . . . . . . . . 9TAMIFLU . . . . . . . . . . . . . . . . . 33tamoxifen . . . . . . . . . . . . . . . . . . 5tamsulosin . . . . . . . . . . . . . . . . 53TANAFED DMX

SUSPENSION . . . . . . . . . . 52TANZEUM . . . . . . . . . . . . . . . . 26TAPAZOLE . . . . . . . . . . . . . . . . 26TARCEVA . . . . . . . . . . . . . . . . . . 4TARGRETIN . . . . . . . . . . . . . . . . 6TASIGNA . . . . . . . . . . . . . . . . . . 5tasimelteon . . . . . . . . . . . . . . . 47TASMAR . . . . . . . . . . . . . . . . . . 16TECFIDERA . . . . . . . . . . . . . . . 15teduglutide . . . . . . . . . . . . . . . . 30TEGRETOL . . . . . . . . . . . . . . . 16TEGRETOL-XR . . . . . . . . . . . . 16temazepam . . . . . . . . . . . . . . . 45TEMODAR . . . . . . . . . . . . . . . . . 4TEMOVATE . . . . . . . . . . . . . . . 19temozolomide . . . . . . . . . . . . . . 4TENEX . . . . . . . . . . . . . . . . . . . . 9TENIVAC . . . . . . . . . . . . . . . . . 59

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tenofovir . . . . . . . . . . . . . . .33, 34TENORETIC . . . . . . . . . . . . . . . 9TENORMIN . . . . . . . . . . . . . . . . 9TERAZOL 3/7 . . . . . . . . . . . . . 39terazosin . . . . . . . . . . . . . . . . 9, 53terbinafine . . . . . . . . . . . . .20, 32terbutaline . . . . . . . . . . . . . . . . 53terconazole . . . . . . . . . . . . . . . 39teriflunomide . . . . . . . . . . . . . . 16tesamorelin . . . . . . . . . . . . . . . 26TESSALON . . . . . . . . . . . . . . . 48TESTOSTERONE 1% TOPICAL

GEL . . . . . . . . . . . . . . . . . . 24testosterone cypionate . . . . . . 24testosterone enanthate . . . . . . 24testosterone gel topical tube,

packet, and pump bottle . 24tet tox-diph-acell pertuss ad . 59TET/DIP TOX INJ . . . . . . . . . . 59tetanus immune globulin

(human) . . . . . . . . . . . . . . . 59tetanus-diphtheria toxoids

(td) . . . . . . . . . . . . . . . . . . . 59tetrabenazine . . . . . . . . . . . . . . 17tetracaine hcl ophth soln . . . . 42tetracycline . . . . . . . . . . . . . . . . 31tetrahydrozoline/zinc sulfate . 40thalidomide . . . . . . . . . . . . . . . . 7THALOMID . . . . . . . . . . . . . . . . 7THEO-24 . . . . . . . . . . . . . . . . . 53THEOCHRON . . . . . . . . . . . . . 53theophylline . . . . . . . . . . . . . . . 53theophylline extended-release 53THERA-PLUS . . . . . . . . . . . . . 54thioguanine . . . . . . . . . . . . . . . . 4thioridazine . . . . . . . . . . . . . . . 48thiothixene . . . . . . . . . . . . . . . . 48THORAZINE . . . . . . . . . . .45, 48THORAZINE INJ . . . . . . . . . . . 45THYROLAR . . . . . . . . . . . . . . . 26tiagabine . . . . . . . . . . . . . . . . . 17TIAZAC . . . . . . . . . . . . . . . . . . . 10ticagrelor . . . . . . . . . . . . . . . . . . 8TIGAN . . . . . . . . . . . . . . . . . . . . 28TIKOSYN . . . . . . . . . . . . . . . . . . 9timolol . . . . . . . . . . . . . . . . . . . . 41

timolol maleate . . . . . . . . . . . . 41TIMOPTIC . . . . . . . . . . . . . . . . 41TIMOPTIC XE . . . . . . . . . . . . . 41TINACTIN . . . . . . . . . . . . . .20, 60tiotropium/olodaterol . . . . . . . 52tipranavir . . . . . . . . . . . . . . . . . 34TIVICAY . . . . . . . . . . . . . . . . . . 33tizanidine . . . . . . . . . . . . . . . . . 37TOBRADEX . . . . . . . . . . . . . . . 40tobramycin . . . . . . . . . 40, 42, 57tobramycin neb soln . . . . . . . . 57tobramycin/dexamethasone . 40TOBREX . . . . . . . . . . . . . . . . . . 42TOFRANIL . . . . . . . . . . . . . . . . 44TOFRANIL-PM . . . . . . . . . . . . . 46tolazamide . . . . . . . . . . . . . . . . 25tolbutamide . . . . . . . . . . . . . . . 25tolcapone . . . . . . . . . . . . . . . . . 16TOLINASE . . . . . . . . . . . . . . . . 25tolnaftate . . . . . . . . . . . . . .20, 60tolterodine . . . . . . . . . . . . . . . . 54TOPAMAX . . . . . . . . . . . . . . . . 17TOPAMAX SPRINKLE . . . . . . 17topical antibacterials . . . . . . . . 61topiramate . . . . . . . . . . . . . . . . 17topiramate sprinkle caps . . . . 17topotecan . . . . . . . . . . . . . . . . . . 7TOPROL XL . . . . . . . . . . . . . . . 10TORADOL . . . . . . . . . . . . . . . . 14toremifene . . . . . . . . . . . . . . . . . 5torsemide . . . . . . . . . . . . . . . . . 11TOUJEO SOLOSTAR . . . . . . . 24TRACLEER . . . . . . . . . . . . . . . 12tramadol . . . . . . . . . . . . . . . . . . 13trametinib . . . . . . . . . . . . . . . . . . 5TRANDATE . . . . . . . . . . . . . . . 10trandolapril . . . . . . . . . . . . . . . . . 8tranexamic acid . . . . . . . . . . . . 40TRANXENE . . . . . . . . . . . . . . . 43tranylcypromine . . . . . . . . . . . . 44trazodone . . . . . . . . . . . . . .44, 47TRECATOR . . . . . . . . . . . . . . . 30TRENTAL . . . . . . . . . . . . . . . . . . 8tretinoin . . . . . . . . . . . . . . . . 7, 18TREXIMET . . . . . . . . . . . . . . . . 15TRI RX . . . . . . . . . . . . . . . . . . . 56

TRI-FED X. . . . . . . . . . . . . . . . . 52TRI-NORINYL . . . . . . . . . . . . . 38TRI-VI-FLOR . . . . . . . . . . . . . . . 56TRI-VI-SOL . . . . . . . . . . . . .56, 63triamcinolone . . . . . . . . . . .19, 23triamcinolone acetonide . . . . 19triamcinolone nasal spray . . . 23triamterene/

hydrochlorothiazide . . . . . 11TRIAVIL . . . . . . . . . . . . . . . . . . 44triazolam . . . . . . . . . . . . . . . . . . 45trifluoperazine . . . . . . . . . . . . . 48trifluridine . . . . . . . . . . . . . . . 4, 42trifluridine/tipiracil . . . . . . . . . . . 4trihexyphenidyl . . . . . . . . . . . . 16TRILAFON . . . . . . . . . . . . . . . . 48TRILEPTAL . . . . . . . . . . . . . . . 17TRILYTE . . . . . . . . . . . . . . . . . . 27trimethobenzamide . . . . . . . . 28trimethoprim . . . . . . . 31, 35, 42trimipramine . . . . . . . . . . . . . . 47TRINTELLIX . . . . . . . . . . . . . . . 47TRIOTANN . . . . . . . . . . . . .23, 48TRIOTANN PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 48tripolidine/pseudoephedrine 52TRIPROL/PSE SYP . . . . . . . . 52TRIUMEQ . . . . . . . . . . . . . . . . . 34TRIVORA . . . . . . . . . . . . . . . . . 38TRIZIVIR . . . . . . . . . . . . . . . . . . 33TROJAN . . . . . . . . . . . . . . . . . . 61trospium . . . . . . . . . . . . . . . . . . 54TRULICITY . . . . . . . . . . . . . . . . 26TRUSOPT . . . . . . . . . . . . . . . . 41TRUST NATALCARE

PAK DHA . . . . . . . . . . . . . . 55TRUSTEX . . . . . . . . . . . . . . . . . 61TRUVADA . . . . . . . . . . . . . . . . 33TUMS . . . . . . . . . . . . . . . . .62, 63TUSSI-12 S . . . . . . . . . . . . . . . 48TUSSIN DM . . . . . . . . . . . . . . . 49tybost . . . . . . . . . . . . . . . . . . . . 34TYKERB . . . . . . . . . . . . . . . . . . . 5TYLENOL . . . . . . . 13, 14, 36, 63

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

TYLENOL W/CODEINE . . . . . 14TYMLOS . . . . . . . . . . . . . . . . . 26typhoid vaccine . . . . . . . . . . . . 59

UULORIC . . . . . . . . . . . . . . . . . . 37ULTRA . . . . . . . . . . . . . . . .25, 56ULTRA 2, ULTRAMINI . . . . . . 25ULTRAM . . . . . . . . . . . . . . . . . . 13ULTRAVATE . . . . . . . . . . . . . . . 19umeclidinium inhalation . . . . . 52UNI-HIST DROPS . . . . . . . . . . 48UNIPHYL . . . . . . . . . . . . . . . . . 53UNIRETIC . . . . . . . . . . . . . . . . . 9UNISOM . . . . . . . . . . . . . . .45, 62UNIVASC . . . . . . . . . . . . . . . . . . 8UREA 10% CREAM . . . . . . . . 21UREA 10% LOTION . . . . . . . . 21urea 10%, urea 20% . . . . . . . . 21UREA 20% CREAM . . . . . . . . 21urea 40% . . . . . . . . . . . . . . . . . 21UREA 40% LOTION . . . . . . . . 21URECHOLINE . . . . . . . . . . . . . 53UREX . . . . . . . . . . . . . . . . . . . . 53uridine . . . . . . . . . . . . . . . . . . . 26UROCIT-K . . . . . . . . . . . . . . . . 54UROXATRAL . . . . . . . . . . . . . . 53URSO . . . . . . . . . . . . . . . . . . . . 30URSO FORTE . . . . . . . . . . . . . 30ursodiol . . . . . . . . . . . . . . . . . . 30UTIRA C . . . . . . . . . . . . . . . . . . 53

VVAGIFEM . . . . . . . . . . . . . . . . . 39vaginal products . . . . . . . . . . . 60valacyclovir . . . . . . . . . . . . . . . . 33valbenazine . . . . . . . . . . . . . . . 17VALCYTE . . . . . . . . . . . . . . . . . 32valganciclovir . . . . . . . . . . . . . . 32VALIUM . . . . . . . . . . . . . . .37, 43valproic acid . . . . . . . . . . . . . . 17VALTREX . . . . . . . . . . . . . . . . . 33VANCOCIN HCL . . . . . . . . . . . 32vancomycin HCl . . . . . . . . . . . 32vandetanib . . . . . . . . . . . . . . . . . 5VAQTA . . . . . . . . . . . . . . . . . . . 58

varenicline . . . . . . . . . . . . . . . . 48varicella virus vac live for

subcutaneous . . . . . . . . . . 59VARIVAX . . . . . . . . . . . . . . . . . 59VARUBI . . . . . . . . . . . . . . . . . . 28VASERETIC . . . . . . . . . . . . . . . . 8VASOCIDIN . . . . . . . . . . . . . . . 40VASOCLEAR . . . . . . . . . . . . . . 40VASOCLEAR A . . . . . . . . . . . . 40VASOTEC . . . . . . . . . . . . . . . . . . 8VECTICAL . . . . . . . . . . . . . . . . 20VEETIDS . . . . . . . . . . . . . . . . . 31VELTASSA . . . . . . . . . . . . . . . . 12vemurafenib . . . . . . . . . . . . . . . . 5VENCLEXTA . . . . . . . . . . . . . . . 5venetoclax . . . . . . . . . . . . . . . . . 5venlafaxine . . . . . . . . . . . . .44, 47venlafaxine HCL tab

SR 24HR . . . . . . . . . . . . . . 47venlafaxine XR . . . . . . . . . . . . . 44VENTOLIN HFA . . . . . . . . . . . . 52VEPESID . . . . . . . . . . . . . . . . . . 6verapamil . . . . . . . . . . . . . .10, 15verapamil extended-release . . 10VERIO . . . . . . . . . . . . . . . . . . . . 25VERIO, VERIO FLEX, VERIO IQ,

VERIO SYNC . . . . . . . . . . . 25VERSACLOZ . . . . . . . . . . . . . . 45VERZENIO . . . . . . . . . . . . . . . . . 4VESANOID . . . . . . . . . . . . . . . . . 7VEXOL . . . . . . . . . . . . . . . . . . . 41VFEND . . . . . . . . . . . . . . . . . . . 32VI-DAYLIN . . . . . . . . . . . . . . . . . 63VI-STRESS . . . . . . . . . . . . . . . . 54VIBRAMYCIN . . . . . . . . . . . . . 31VICODIN . . . . . . . . . . . . . . . . . . 14VICODIN ES . . . . . . . . . . . . . . . 14VIDEX . . . . . . . . . . . . . . . . . . . . 33VIDEX EC . . . . . . . . . . . . . . . . . 33vigabatrin oral solution . . . . . . 17VIIBRYD . . . . . . . . . . . . . . . . . . 47vilazodone . . . . . . . . . . . . . . . . 47VIMPAT . . . . . . . . . . . . . . . . . . . 17VINATE AZ EX . . . . . . . . . . . . . 55VINATE II . . . . . . . . . . . . . . . . . 55VIRACEPT . . . . . . . . . . . . . . . . 34

VIRAMUNE . . . . . . . . . . . . . . . 34VIRAMUNE XR . . . . . . . . . . . . 34VIREAD . . . . . . . . . . . . . . . . . . 34VIROPTIC . . . . . . . . . . . . . . . . . 42VISINE . . . . . . . . . . . . . . . . . . . 63VISINE-AC . . . . . . . . . . . . . . . . 40vismodegib . . . . . . . . . . . . . . . . 7VISTARIL . . . . . . . . . . . . . . . . . 22VISTOGARD . . . . . . . . . . . . . . 26vitamin A . . . . . . . . . . . . . . . . . 56vitamin ADC/fluoride/±iron

drops . . . . . . . . . . . . . . . . . 56vitamin B complex/vitamin C/

folic acid . . . . . . . . . . . . . . . 56vitamin B-1 . . . . . . . . . . . . . . . . 56VITAMIN B-12 . . . . . . . . . . . . . 54vitamin B-6 . . . . . . . . . . . . . . . . 56vitamin C . . . . . . . . . . . . . . . . . 56vitamin D . . . . . . . . . . . . . .56, 63vitamin D 400 IU . . . . . . . . . . . 63vitamin E. . . . . . . . . . . . . . . . . . 56vitamins pediatric . . . . . . .56, 63vitamins pediatric members <3

years old . . . . . . . . . . . . . . 63vitamins prenatal . . . . . . . . . . . 63VIVACTIL . . . . . . . . . . . . . . . . . 46VIVOTIF BERNA . . . . . . . . . . . 59VOLTAREN . . . . . 13, 14, 36, 40VOLTAREN 1% TOPICAL

GEL . . . . . . . . . . . . . . . . . . 36VOLTAREN XR . . . . . . . . .14, 36voriconazole . . . . . . . . . . . . . . 32vorinostat . . . . . . . . . . . . . . . . . . 4vortioxetine. . . . . . . . . . . . . . . . 47VOSOL HC OTIC . . . . . . . . . . 22VOSOL OTIC . . . . . . . . . . . . . . 22VOSPIRE ER . . . . . . . . . . . . . . 53VOTRIENT . . . . . . . . . . . . . . . . . 5VYVANSE . . . . . . . . . . . . . . . . 43VYVANSE CHEWABLE . . . . . 43

Wwarfarin . . . . . . . . . . . . . . . . . . . 7WELLBUTRIN . . . . . . . . . . . . . 44WELLBUTRIN SR . . . . . . . . . . 44WELLBUTRIN XL . . . . . . . . . . 44

84

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

Index of Covered DrugsWELLCOVORIN . . . . . . . . . . . . 7WESTCORT . . . . . . . . . . . . . . . 19WYTENSIN . . . . . . . . . . . . . . . 12

XXALATAN . . . . . . . . . . . . . . . . . 41XALKORI . . . . . . . . . . . . . . . . . . 4XANAX . . . . . . . . . . . . . . . . . . . 42XARELTO . . . . . . . . . . . . . . . . . . 7XELODA . . . . . . . . . . . . . . . . . . . 4XENAZINE . . . . . . . . . . . . . . . . 17XIIDRA . . . . . . . . . . . . . . . . . . . 42XOLAIR . . . . . . . . . . . . . . . . . . 52XOPENEX RESPULES . . . . . . 53XULANE . . . . . . . . . . . . . . . . . . 38XYLOCAINE . . . . . . . . . . . .21, 23XYZAL . . . . . . . . . . . . . . . . . . . 22

YYUVAFEM . . . . . . . . . . . . . . . . 39

Zzaleplon . . . . . . . . . . . . . . . . . . 45ZANAFLEX . . . . . . . . . . . . . . . 37zanamivir . . . . . . . . . . . . . . . . . 33ZANTAC . . . . . . . . . . . . . . . . . . 28ZARONTIN . . . . . . . . . . . . . . . 16ZAROXOLYN . . . . . . . . . . . . . . 11ZARXIO . . . . . . . . . . . . . . . . . . . 7ZEBETA . . . . . . . . . . . . . . . . . . . 9ZEJULA . . . . . . . . . . . . . . . . . . . 7ZELBORAF . . . . . . . . . . . . . . . . 5ZENPEP . . . . . . . . . . . . . . . . . . 29ZENTANE . . . . . . . . . . . . . . . . . 18ZERIT . . . . . . . . . . . . . . . . . . . . 33ZESTORETIC . . . . . . . . . . . . . . 8ZESTRIL . . . . . . . . . . . . . . . . . . . 8zetia . . . . . . . . . . . . . . . . . . . . . . 11ZIAC . . . . . . . . . . . . . . . . . . . . . . 9ZIAGEN . . . . . . . . . . . . . . . . . . 33zidovudine . . . . . . . . . . . . . . . . 33ZINBRYTA . . . . . . . . . . . . . . . . 15zinc . . . . . . . . . . . . . . . 40, 54, 56zinc sulfate . . . . . . . . . . . . .40, 56ZINCATE . . . . . . . . . . . . . . . . . 56ziprasidone . . . . . . . . . . . . . . . 47

ZITHROMAX . . . . . . . . . . . . . . 31ZOCOR. . . . . . . . . . . . . . . . . . . 11ZOFRAN . . . . . . . . . . . . . . . . . . 27ZOFRAN ODT . . . . . . . . . . . . . 27ZOHYDRO ER . . . . . . . . . . . . . 14ZOLINZA . . . . . . . . . . . . . . . . . . 4ZOLOFT . . . . . . . . . . . . . . . . . . 44zolpidem . . . . . . . . . . . . . . . . . 45ZOMACTON . . . . . . . . . . . . . . 26ZONEGRAN . . . . . . . . . . . . . . 17zonisamide . . . . . . . . . . . . . . . 17ZORTRESS . . . . . . . . . . . . . . . . 6ZOSTAVAX . . . . . . . . . . . . . . . . 59zoster vaccine live . . . . . . . . . . 59ZOVIA 1/35 . . . . . . . . . . . . . . . 38ZOVIA 1/50 . . . . . . . . . . . . . . . 38ZOVIRAX . . . . . . . . . . . . . . . . . 33ZYBAN . . . . . . . . . . . . . . . . . . . 48ZYDELIG . . . . . . . . . . . . . . . . . . 5ZYKADIA . . . . . . . . . . . . . . . . . . 4ZYLOPRIM . . . . . . . . . . . . . . . . 37ZYMAR . . . . . . . . . . . . . . . . . . . 42ZYPREXA . . . . . . . . . . . . .46, 47ZYPREXA RELPREVV . . . . . . 46ZYPREXA ZYDIS . . . . . . . . . . 46ZYRTEC . . . . . . . . . . . . . . .22, 60ZYRTEC CHEWABLE

TABLET . . . . . . . . . . . . . . . 22ZYRTEC D . . . . . . . . . . . . . . . . 60ZYRTEC-D . . . . . . . . . . . . . . . . 23ZYTIGA . . . . . . . . . . . . . . . . . . . 5ZYVOX . . . . . . . . . . . . . . . . . . . 35

85

“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 Medicineand Strength

DrugTier

I Take ThisMedicine For Directions Doctor

Example: Lisinopril, 20mg Tier 1 High blood pressure One tablet daily Dr. Johnson

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