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Preferred Drug List (PDL)Maryland Effective Date: 7/1/18

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UnitedHealthcare Community Plan List of Preferred Drugs Frequently Asked Questions (FAQ) Find answers here to questions you have about this UnitedHealthcare Community Plan List of Preferred Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What drugs are on the Preferred Drug List (PDL)? (We call the Preferred Drug List the “Drug List” for short.) The drugs on the Drug List that starts on page <4> are the drugs covered by UnitedHealthcare Community Plan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies”. UnitedHealthcare will cover all medically necessary drugs if both of these things happen:

Your doctor or other prescriber gives you a prescription You fill the prescription at a UnitedHealthcare Community Plan network

pharmacy

You may have to pay a copay when you fill your prescriptions. Also, UnitedHealthcare may have additional steps to get certain drugs (see question <#5> below). You can also see an up-to-date Drug List on our website at <www.myuhc.com/CommunityPlan> or call Member Services at <1-800-318-8821> TTY 711. 2. Does the Drug List ever change? Yes. During the year, UnitedHealthcare Community Plan may add or remove drugs on the Drug List. Generally, the Drug List will change when:

A cheaper drug that works as well as a drug on the Drug List now becomes available

A new drug is approved We learn that a drug is not safe

We may also change our rules about drugs. For example, we could:

Decide to require or not require prior approval for a drug. (Prior approval is permission from UnitedHealthcare Community Plan before you can get a drug.)

Add or change the amount of a drug you can get (called “Quantity limits”).

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Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

For more information on these drug rules, see pages <4, 5 and 9>. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can also see an up-to-date Drug List on our website at <www.myuhc.com/CommunityPlan>, or, call Member Services at <1-800-318-8821>, TTY <711>. 3. What happens when another drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because another drug that works just as well is available, we will tell you. You will get a letter letting you know about the change. We will also tell you what alternate drugs are available to you. Contact your doctor or other prescriber to make sure another drug will work for you. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we’ll take it off the Drug List right away. We’ll also send you a letter telling you that. Contact your doctor or other prescriber and ask about your other options. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases your doctor must do something before you can get the drug. For example:

Prior approval (or prior authorization): For some drugs, your doctor or other prescriber must get approval from UnitedHealthcare before you fill your prescription. If you don’t get approval, UnitedHealthcare may not cover the drug.

Quantity limits: Sometimes UnitedHealthcare limits the amount of a drug you can get.

Step therapy: Sometimes UnitedHealthcare requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on pages <4-54>. You can also get more information by visiting our website at <www.myuhc.com/CommunityPlan>. We have posted documents that explain our prior authorization and step therapy restrictions. You may also call

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Member Services and ask us to send you information about our prior authorization and step therapy restrictions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The Preferred Drug List on pages <4-54> has a column labeled “Requirements and Limits”. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you before the restriction is added. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug:

You can search by medical condition. o To search by medical condition, find the section labeled “List of drugs

by medical condition” on pages <4-54>. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.

You can also search for drugs alphabetically. o To search alphabetically, go to the <Index of Covered Drugs> starting

on page <55> Find the name of your drug. The page number where you can find the drug will be next to it. 9. What if the drug you want to take is not on the Drug List? If you don’t see your drug on the Drug List, call Member Services and ask about it. If you learn that UnitedHealthcare does not prefer the drug, you can do one of these things:

Ask Member Services for a list of drugs that are similar to the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take.

You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions.

10. What if you just joined UnitedHealthcare Community Plan and can’t find your drug on the Drug List or have a problem getting your drug?

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We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead, or whether to request an exception. 11. Can you ask for an exception to cover your drug? Yes. Your doctor can ask UnitedHealthcare Community Plan to make an exception to cover a drug that is not on the Drug List. Your doctor can also ask us to change the rules on your drug.

For example, we may limit the amount of a drug we will cover. If your drug has a limit, your doctor can ask us to change the limit and cover more.

Other examples: Your doctor can ask us to drop step therapy restrictions or prior approval requirements.

12. How long does it take to get an exception? First, we must receive some information from your doctor supporting your request for an exception. After we receive the information, we will give you a decision on your exception request within the timeframes required by the state, generally within 24 hours. 13. How can you ask for an exception? To ask for an exception, you can do one of these things:

Call Member Services. A Member Services representative will work with you and your doctor to help ask for an exception.

Call your doctor and ask them to request an exception by calling the Prior Notification Service at <1-800-310-6826>, or they can fax a request to <866-940-7328>.

14. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). In most instances UnitedHealthcare covers generic drugs first. If your doctor feels a brand name drug is medically necessary, you will need to ask your doctor to submit for prior approval. 15. What are OTC drugs? OTC stands for “over-the-counter”. UnitedHealthcare prefers some OTC drugs when they are written as prescriptions by your provider. You can read the UnitedHealthcare Community Plan Drug List to see what OTC drugs are preferred. 16. Does UnitedHealthcare cover OTC non-drug products?

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UnitedHealthcare covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the UnitedHealthcare Community Plan Drug List to see what OTC non-drug products are covered. 17. What is a Specialty Pharmacy Medication? A specialty pharmacy medication is a drug that generally has one or more of the following characteristics:

It’s used by a small number of people It treats rare, chronic, and/or potentially life-threatening diseases It has special storage or handling requirements such as needing to be

refrigerated It may need close monitoring, ongoing clinical support and management, and

complete patient education and engagement It’s a high cost medication It may not be available at retail pharmacies It may be oral, injectable, or inhaled

Specialty pharmacy medications are available through our specialty pharmacy network. If you have questions, call Member Services at <1-800-318-8821, TTY 711>. List of Preferred Drugs The List of Preferred Drugs that begins <on the next page> gives you information about the drugs covered by UnitedHealthcare Community Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page <55>. The first column of the chart lists the generic name of the drug. The second column of the chart lists brand name drugs. Brand name drugs are capitalized (e.g., CRESTOR). The third column in the list tells you if the preferred drug covered is the brand or generic version. The information in the “Requirements & Limits” column tells you if UnitedHealthcare has any rules for covering your drug. Utilization Management Restrictions PA - Prior approval (or prior authorization)

For some drugs, your doctor or other prescriber must get approval from UnitedHealthcare Community Plan before you fill your prescription. If you don’t get approval, UnitedHealthcare may not cover the drug.

QL - Quantity limits

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Sometimes UnitedHealthcare Community Plan limits the amount of a drug you can get.

ST - Step therapy Sometimes UnitedHealthcare Community Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then your doctor can ask for approval to cover the second.

Other special requirements for coverage SP – Specialty Pharmacy

Drug needs to be accessed through a network Specialty Pharmacy. Specialty Pharmacy Drugs may require extra handling, provider coordination or patient education that can’t be done at a network retail pharmacy.

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

[Abbreviations] OTC = Over the Counter PA = Prior Authorization required QL = Quantity Limit ST = Step Therapy SP = Specialty Pharmacy [You can find information on what the symbols and abbreviations in this table mean by going to page <4-54 in the footnotes>]

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

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

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

Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Calcium Channel Blockers. . . . . . . . . . . . . . . . . . 9Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Lipid Lowering Agents . . . . . . . . . . . . . . . . . . . . 11Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Potassium-Removing Agents . . . . . . . . . . . . . . . 12Pulmonary Arterial Hypertension . . . . . . . . . . . 12Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Central Nervous System. . . . . . . . . . . . . . . .12Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 12Amyotrophic Lateral Sclerosis (ALS) . . . . . . . . 13Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 14Migraine Prophylactic Therapy . . . . . . . . . . . . . 15Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . 15Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . . 15Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 15Seizure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . .16Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 16Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . 17Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 18Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Scabies and Pediculosis. . . . . . . . . . . . . . . . . . . 18Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . .20Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 21

Endocrinology . . . . . . . . . . . . . . . . . . . . . . . .22Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 22Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 22Growth Stimulating Agents. . . . . . . . . . . . . . . . . 24Lipodystropy Agents . . . . . . . . . . . . . . . . . . . . . . 24Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 24Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Gastrointestinal. . . . . . . . . . . . . . . . . . . . . . .25Constipation/Laxatives . . . . . . . . . . . . . . . . . . . . 25Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Emesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Gastroesophageal Reflux Disease (Gerd)/

Peptic Ulcers. . . . . . . . . . . . . . . . . . . . . . . . . . . 26Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . . 27Inflammatory Bowel Disease . . . . . . . . . . . . . . . 27Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 27Probiotic Supplementation. . . . . . . . . . . . . . . . . 27Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Infectious Diseases . . . . . . . . . . . . . . . . . . .28Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Antiprotozoals. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

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Musculoskeletal . . . . . . . . . . . . . . . . . . . . . .32Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 33Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Hormone Therapy/Menopause. . . . . . . . . . . . . 35Ovulation Stimulants . . . . . . . . . . . . . . . . . . . . . . 36 Vaginal Infections. . . . . . . . . . . . . . . . . . . . . . . . . 36Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . .36Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 36Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Immunologic Agents . . . . . . . . . . . . . . . . . . . . . . 38Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Psychiatric. . . . . . . . . . . . . . . . . . . . . . . . . . .39Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Narcotic Antagonist . . . . . . . . . . . . . . . . . . . . . . . 39Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Respiratory Drugs. . . . . . . . . . . . . . . . . . . . .39Antitussives, Decongestants, Expectorants

and Combinations . . . . . . . . . . . . . . . . . . . . . . 39Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Urological . . . . . . . . . . . . . . . . . . . . . . . . . . .44Symptomatic Benign Prostatic Hypertrophy . . 44Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Vitamins and Minerals . . . . . . . . . . . . . . . . .45Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . .48Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Antidotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 48Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 48Idiopathic Pulmonary Fibrosis (IPF) . . . . . . . . . 48Immune Thrombocytopenic Purpura . . . . . . . . 48Medical Devices. . . . . . . . . . . . . . . . . . . . . . . . . . 48Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . . 49Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

OTC MEDICATIONS . . . . . . . . . . . . . . . . . . .51Acne. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 51Cough/Cold Allergy. . . . . . . . . . . . . . . . . . . . . . . 51Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Earwax Removal Products . . . . . . . . . . . . . . . . . 52Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 52First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 52Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Motion Sickness. . . . . . . . . . . . . . . . . . . . . . . . . . 53Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . 54Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Index of Covered Drugs . . . . . . . . . . . . . . . .55

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

ST = Step TherapySP = Specialty Pharmacy

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

Antineoplastics & Immunosuppressants

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

phosphate sodium EMCYT brand 2

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

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

everolimusAFINITORAFINITOR DISPERZ

brand 2 PA, SP

gefitinib IRESSA brand 2 PA, SPibrutinib IMBRUVICA brand 2 PA, SPidelalisib ZYDELIG brand 2 PA, SP

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imatinib 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 Inhibitorsixazomib 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 1Gonadotropin Releasing Hormone Analogleuprolide LUPRON generic 1 PA, SP

leuprolideLUPRON DEPOTLUPRON DEPOT 6-MONTHLUPRON DEPOT-PED

brand 2 PA, SP

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Progestinmegestrol acetate MEGACE generic 1ImmunomodulatorsInterferonsinterferon alfa-2b INTRON A brand 2 PA, SPinterferon gamma-1b ACTIMMUNE brand 2 PA, SPpeginterferon alfa-2b SYLATRON brand 2 PA, SPMiscellaneouslenalidomide REVLIMID brand 2 PA, SPpomalidomide POMALYST brand 2 PA, SPthalidomide THALOMID brand 2 PA, SP, QLImmunosuppressantsAntimetabolitesazathioprine IMURAN generic 1mycophenolate mofetil CELLCEPT generic 1mycophenolate sodium MYFORTIC generic 1Calcineurin Inhibitorscyclosporine SANDIMMUNE generic 1

cyclosporine, modifiedNEORALGENGRAF

generic 1 caps, QL

tacrolimusHECORIA PROGRAF

generic 1

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

topical gel TARGRETIN brand 2 PA, SP

cysteamine bitartrate CYSTAGON brand 2 SPetoposide VEPESID generic 1hydroxyurea DROXIA brand 2hydroxyurea HYDREA generic 1mitotane LYSODREN brand 2niraparib ZEJULA brand 2 PA, SPoctreotide SANDOSTATIN generic 1 SPolaparib LYNPARZA brand 2 PA, SPpasireotide SIGNIFOR brand 2 PA, SP

7




procarbazine MATULANE brand 2 SPrucaparib RUBRACA brand 2 PA, SPsonidegib ODOMZO 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 PA, QL

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

rivaroxaban XARELTO brand 2 QLwarfarin COUMADIN 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

aspirinBAYERECOTRIN

generic 1 OTC

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

deferasiroxEXJADEJADENU

brand 2 PA, SP

emicizumab-kxwh HEMLIBRA brand 2 PA, QL, SP

8




pentoxifylline 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 QLquinapril ACCUPRIL generic 1 QLramipril ALTACE generic 1trandolapril MAVIK generic 1Ace Inhibitor/Diuretic Combinationsbenazepril/

hydrochlorothiazide LOTENSIN HCT generic 1

captopril/ hydrochlorothiazide CAPOZIDE generic 1

enalapril/ hydrochlorothiazide VASERETIC generic 1

fosinopril/ hydrochlorothiazide MONOPRIL-HCT generic 1 QL

lisinopril/ hydrochlorothiazide ZESTORETIC generic 1 QL

quinapril/ hydrochlorothiazide ACCURETIC generic 1 QL

Adrenolytics, Centralclonidine CATAPRES generic 1 tabletsguanfacine TENEX generic 1Alpha Blockersdoxazosin CARDURA generic 1prazosin MINIPRESS generic 1terazosin HYTRIN generic 1Angiotensin II Receptor Blockers (Antagonists)losartan COZAAR generic 1 QL

9




Angiotensin 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 QLlabetalol TRANDATE generic 1metoprolol LOPRESSOR generic 1 25, 50, 100mg tabletsmetoprolol succinate TOPROL XL generic 1propranolol INDERAL generic 1 IR onlypropranolol 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 1

10




nifedipine 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

Diureticsamiloride MIDAMOR generic 1amiloride/

hydrochlorothiazide MODURETIC generic 1

bumetanide BUMEX generic 1chlorothiazide DIURIL generic 1

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

11




Lipid Lowering AgentsBile Acid Resin

cholestyramineQUESTRANQUESTRAN-LIGHT

generic 1

Only the bulk products are covered (cans).

Individual packets are not covered.

Fibratesfenofibrate LOFIBRA generic 1 STgemfibrozil LOPID generic 1HMG-CoA Reductase Inhibitors and Combinationsatorvastatin LIPITOR generic 1 QLlovastatin MEVACOR generic 1 QLsimvastatin ZOCOR generic 1 QLNiacinsniacin 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 PANitratesOralisosorbide 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 1

nitroglycerinNITROLINGUALNITROSTAT

generic 1

Transdermal

nitroglycerinNITREK NITRO-DUR

generic 1 transdermal, QL

nitroglycerin NITRO-BID generic 1 oint

12




Potassium-Removing Agentspatiromer VELTASSA brand 2 PAsodium polystyrene

sulfonate KAYEXALATE generic 1 susp only

Pulmonary Arterial Hypertension - Diagnosis Requiredambrisentan LETAIRIS brand 2 QL, SPbosentan TRACLEER brand 2 QL, SPmacitentan OPSUMIT brand 2 QL,SPriociguat ADEMPAS brand 2 QL, SPsildenafil REVATIO generic 1 QL, SP, tabsMiscellaneousguanabenz WYTENSIN generic 1hydralazine APRESOLINE generic 1methyldopa ALDOMET generic 1methyldopa/HCTZ ALDORIL generic 1midodrine PROAMATINE generic 1minoxidil LONITEN generic 1ranolazine RANEXA brand 2 ST

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

authorization.

13




Amyotrophic Lateral Sclerosis (ALS)riluzole RILUTEK generic 1AnalgesicsBarbiturate Non-Narcotic Analgesicsbutalbital/acetaminophen PHRENILIN generic 1 QLbutalbital/acetaminophen SEDAPAP generic QL

butalbital/acetaminophen/caffeine

ESGIC FIORICETZEBUTAL

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 QLNSAIDSdiclofenac potassium CATAFLAM generic 1diclofenac sodium

delayed-release VOLTAREN generic 1

diclofenac sodium extended-release VOLTAREN XR generic 1

etodolac LODINE generic 1 IR Only

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 1 IR onlyketorolac tromethamine TORADOL generic 1 QLmeloxicam MOBIC generic 1 QLnabumetone RELAFEN generic 1naproxen NAPROSYN generic 1

naproxen delayed release ENTERIC COATED-NAPROSYN generic 1

oxaprozin DAYPRO generic 1piroxicam FELDENE generic 1sulindac CLINORIL generic 1

14




Opioids - 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 PA, QLhydromorphone DILAUDID generic 1 QLmeperidine DEMEROL generic 1 QL

morphineMSIRRMS

generic 1 QL

morphine extended-release MS CONTIN generic 1 PA, QL

oxycodone OXYFAST generic 1 soln, QLoxycodone ROXICODONE generic 1 QL, tabsoxycodone/

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

oxycodone/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

15




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

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

Migraine Prophylactic Therapypropranolol INDERAL generic 1 IR onlyverapamil CALAN generic 1Multiple Sclerosis - Diagnosis Requireddaclizumab ZINBRYTA brand 2 QL, SP, STdimethyl fumarate TECFIDERA brand 2 QL, SPfingolimod GILENYA brand 2 QL, SPglatiramer acetate COPAXONE generic 1 QL, SPglatiramer acetate GLATOPA generic 1 QL, SPpeginterferon beta-1a PLEGRIDY brand 2 QL, SPteriflunomide AUBAGIO brand 2 QL, SPMyasthenia 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 1Seizurephenobarbital PHENOBARBITAL generic 1phenytoin DILANTIN INFATABS generic 1phenytoin sodium

extended DILANTIN, PHENYTEK generic 1

primidone MYSOLINE generic 1

16




Miscellaneoustetrabenazine XENAZINE generic 1 Diagnosis Required, QL, SPvalbenazine INGREZZA brand 2 PA, QL, SP

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 soln

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

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

tretinoinAVITA RETIN-A

generic 1 cream, ST

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

17




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 soln 0.05%halobetasol ULTRAVATE generic 1 cream

18




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 1 crm/oint, STcalcipotriene DOVONEX generic 1 solncalcitriol VECTICAL generic 1 STmethoxsalen OXSORALEN-ULTRA generic 1salicylic acid SCALPICIN generic 1 liquid 3%Rosaceabrimonidine MIRVASO brand 2 PA

metronidazoleMETROCREAMMETROGELMETROLOTION

generic 1

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

butoxide shampoo RID SHAMPOO generic 1 4% OTC

spinosad NATROBA generic 1 QLViral Infectionspodofilox CONDYLOX SOL generic 1 solsalicylic acid 17%/

collodion DUOFILM generic 1 OTC

19




Miscellaneousaluminum acetate brand 2 soln/cream, OTCaluminum chloride topical

solution HYPERCARE 15% brand 2

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

ammonium lactate LACTINOL generic 1 lotion 10%becaplermin gel REGRANEX brand 2 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 Required, QLlidocaine/prilocaine EMLA generic 1 2.5% cream

nitroglycerin RECTIV brand 2 Diagnosis Required, QL, 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 1

ointment 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)

20




urea 10%, urea 20%UREA 10% CREAMUREA 20% CREAMUREA 10% LOTION

brand 2

urea 40% UREA 40% LOTION generic 1 lotion

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, QL

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 OTCAntihistamines - Second Generation, Nonsedatingcetirizine ZYRTEC generic 1 OTC

cetirizine chew tab ZYRTEC CHEWABLE TABLET generic 1

OTC, Members ≥ 8 years of age will require prior

authorization.levocetirizine XYZAL generic 1 tabs

loratadineALAVERTCLARITIN

generic 1 OTC

Antihistamines - Others Antihistamine/Decongestant Combinationsazelastine ASTELIN generic 1 spray

21




Antihistamine/Decongestant Combinations - First Generationchlorpheniramine/

phenylephrine/ pyrilamine

TRIOTANN generic 1

chlorpheniramine/ pseudoephedrine ACTIFED generic 1 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 Nasalcromolyn sodium NASALCROM generic 1 OTCipratropium nasal ATROVENT NASAL SPRAY generic 1 QLsaline nasal spray 0.65% OCEAN NASAL SPRAY generic 1 OTCMiscellaneous Nasal Decongestantsoxymetazoline AFRIN generic 1 OTC

phenylephrineNEO-SYNEPHRINE DIMEATAPP DRO

DECONGESgeneric 1 OTC

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

22




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 units/ml TOUJEO SOLOSTAR brand 2

23




insulin human NOVOLIN R brand 2 OTC, QL, vialsinsulin human RELION R brand 2 OTC, QL, vialsinsulin isophane HUMULIN N brand 2 OTC, QL, vialsinsulin isophane human NOVOLIN N brand 2 OTC, QL, vialsinsulin isophane human RELION N brand 2 OTC, QL, vialsinsulin isophane human

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

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

insulin lisopro pro/lispro HUMALOG MIX 50/50 brand 2 QL, vialsinsulin lisopro prot/lispro HUMALOG MIX 75/25 brand 2 QL, vialsinsulin isophane/regular HUMULIN 70/30 brand 2 OTC, QL, vialsinsulin lispro ADMELOG SOLOSTAR brand 2 PA, QLinsulin lispro ADMELOG VIALS brand 2 QLinsulin 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 1glyburide MICRONASE generic 1

24




glyburide, 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 1Miscellaneous Antidiabetic Agentsalbiglutide TANZEUM brand 2 STdulaglutide TRULICITY brand 2 STlixisenatide ADLYXIN brand 2 STpramlintide SYMLIN brand 2 PAGrowth Stimulating Agentsmecasermin INCRELEX brand 2 PA, SPsomatropin ZOMACTON brand 2 PA, SPLipodystropy Agentstesamorelin EGRIFTA brand 2 Diagnosis Required, QL, 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 QLmethylergonovine METHERGINE generic 1

25




mifepristone KORLYM brand 2 PA, SPnitisinone NITYR brand 2 Diagnosis Required, QL, SPpegvisomant SOMAVERT brand 2 PA, SPsapropterin KUVAN brand 2 Diagnosis Required, QL, SP

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

uridine VISTOGARD brand 2

Gastrointestinal

Constipation/Laxativescasanthranol-docusate

sodium generic 1 OTC

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

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 Required, QLdiphenoxylate/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

26




ondansetronZOFRANZOFRAN ODT

generic 1 QL

prochlorperazine COMPAZINE generic 1promethazine PHENERGAN generic 1rolapitant 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.

27




Gastrointestinal Spasmdicyclomine BENTYL generic 1 tablets onlyglycopyrrolate ROBINUL generic 1hyoscyamine sulfate LEVSIN generic 1hyoscyamine sulfate

extended-release LEVSINEX generic 1

Inflammatory Bowel Diseasebalsalazide COLAZAL generic 1budesonide ENTOCORT EC generic 1 Diagnosis Required, QLhydrocortisone 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

28




probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

brand 2 OTC

Miscellaneousatropine sulfate SAL-TROPINE brand 2misoprostol CYTOTEC generic 1naloxegol MOVANTIK brand 2 Diagnosis Required, QLteduglutide GATTEX brand 2 PA, SP

ursodiolACTIGALL URSO URSO FORTE

generic 1

Infectious Diseases

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

pyrantel pamoate PIN-X brand 2 chewable tablets, suspension

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

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

29




ethionamide TRECATOR brand 2isoniazid ISONIAZID generic 1pyrazinamide PYRAZINAMIDE generic 1rifabutin MYCOBUTIN generic 1rifampin RIFADIN generic 1rifapentine PRIFTIN brand 2Cephalosporins - First Generationcefadroxil DURICEF generic 1cephalexin KEFLEX generic 1 tabs are not coveredCephalosporins - Second Generationcefaclor CECLOR generic 1cefprozil CEFZIL generic 1cefuroxime axetil CEFTIN generic 1 tabscefuroxime axetil CEFTIN brand 2 suspensionCephalosporins - Third Generationcefdinir OMNICEF generic 1cefixime SUPRAX brand 2 400 mg caps only, QLFluoroquinolonesciprofloxacin CIPRO generic 1levofloxacin LEVAQUIN generic 1 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 tabsamoxicillin AMOXIL SUSP generic 1 suspension

30




amoxicillin/clavulanate AUGMENTIN generic 1ampicillin PRINCIPEN generic 1dicloxacillin DICLOXACILLIN generic 1penicillin VK VEETIDS generic 1Sulfonamidessulfamethoxazole/

trimethoprim, DSBACTRIMBACTRIM DS

generic 1

Tetracyclines

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

minocycline MINOCIN generic 1 capsules, except 75 mgMiscellaneousvancomycin HCl VANCOCIN HCL generic 1 cap, STAntiprotozoalsatovaquone MEPRON generic 1 PAbenznidazole BENZNIDAZOLE brand 2 PA, QLmiltefosine IMPAVIDO brand 2 PA

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

authorization.nitazoxanide tablet ALINIA brand 2 PApentamidine isethionate

for nebulization NEBUPENT brand 1

Antifungalsclotrimazole 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 QLvoriconazole VFEND generic 1 PAAntiviralsCytomegalovirus Treatmentganciclovir CYTOVENE generic 1valganciclovir VALCYTE generic 1 tabs only

31




Hepatitis 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, SPlamivudine EPIVIR HBV brand 2 solution, SPpeginterferon alfa-2a PEGASYS brand 2 PA, SPpeginterferon alfa-2a PEGASYS PROCLICK brand 2 PA, SP

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

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 QLMiscellaneousbedaquiline 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 1

32




povidone-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 CIMZIA brand 2 PA, SPetanercept ENBREL brand 2 PA, SPhydroxychloroquine PLAQUENIL generic 1leflunomide ARAVA generic 1methotrexate generic 1penicillamine DEPEN TITRATABLE brand 2 Diagnosis Required, QL, SPsarilumab KEVZARA brand 2 PA, QL, SPsecukinumab 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 2 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 sodium delayed-release VOLTAREN generic 1

diclofenac potassium CATAFLAM generic 1

33




diclofenac sodium extended-release VOLTAREN XR generic 1

etodolac LODINE generic 1 IR only

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

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

naproxen delayed release ENTERIC COATED-NAPROSYN generic 1

oxaprozin DAYPRO generic 1piroxicam FELDENE generic 1salsalate DISALCID generic 1 QLsulindac CLINORIL generic 1Goutallopurinol ZYLOPRIM generic 1colchicine MITIGARE brand 2febuxostat ULORIC brand 2 STprobenecid PROBENECID generic 1Skeletal Muscle RelaxantsMuscle Spasmchlorzoxazone PARAFON FORTE DSC generic 1cyclobenzaprine FLEXERIL generic 1 5mg & 10mgmethocarbamol ROBAXIN generic 1orphenadrine

extended-release NORFLEX generic 1

Spasticitybaclofen BACLOFEN generic 1dantrolene DANTRIUM generic 1tizanidine ZANAFLEX generic 1 tabs only, QLMiscellaneousmilnacipran SAVELLA brand 2 PA

34




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, QLnorethindrone acetate/EE/

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

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

35




norethindrone/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 1Transdermal

norelgestromin/EEORTHO EVRAXULANE

generic 1

Triphasicdesogestrel/EE CYCLESSA generic 1 QLlevonorgestrel/EE TRIVORA generic 1 QLnorethindrone/EE TRI-NORINYL generic 1 QLnorethindrone/EE ORTHO-NOVUM 7/7/7 generic 1 QLnorethindrone

acetate/EE/iron ESTROSTEP FE generic 1 QL

norgestimate/EE ORTHO TRI-CYCLEN generic 1 QLEndometriosisdanazol DANOCRINE generic 1Hormone Therapy/MenopauseEstrogens - Intravaginalestradiol ESTRACE CRM brand 2estrogens, conjugated PREMARIN brand 2 crmyuvafem or estradiol

vaginal tablets VAGIFEM generic 1 QL

Estrogens - Oralestradiol ESTRACE generic 1estrogens, conjugated PREMARIN brand 2estropipate OGEN generic 1Estrogens - Transdermalestradiol CLIMARA generic 1 QLEstrogen/Progestinestrogens, conjugated/

medroxyprogesteronePREMPHASEPREMPRO

brand 2

Progestinsmedroxyprogesterone

acetate PROVERA generic 1

norethindrone acetate AYGESTIN generic 1progesterone micronized

cap PROMETRIUM generic 1 Diagnosis Required, QL

36




Ovulation Stimulantschoriogonadotropin alfa OVIDREL brand 2 Diagnosis Required, QLchorionic gonadotropin NOVAREL brand 2 Diagnosis Required, QLVaginal InfectionsOralfluconazole DIFLUCAN generic 1 QLmetronidazole FLAGYL generic 1 tabsVaginalclotrimazole GYNE-LOTRIMIN generic 1 OTCclindamycin CLEOCIN generic 1 crm

metronidazoleMETROGEL-VAGINAL METROGEL 1%

generic 1

miconazole MONISTAT generic 1 OTCmiconazole MONISTAT 3 generic 1terconazole TERAZOL 3/7 generic 1 crmMiscellaneousconjugated 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-InflammatoriesNonsteroidaldiclofenac sodium VOLTAREN generic 1flurbiprofen OCUFEN generic 1ketorolac ACULAR/ACULAR LS generic 1

37




Steroidaldexamethasone sodium

phosphate DEXASOL generic 1

fluorometholone FML brand 2 oint 0.1%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%Anti-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

GlaucomaBeta-Blockerscarteolol generic 1levobunolol 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 2

38




Mydriaticsatropine ISOPTO ATROPINE generic 1cyclopentolate CYCLOGYL generic 1 1%homatropine ISOPTO HOMATROPINE generic 1 5%homatropine ISOPTO HOMATROPINE brand 2 2%scopolamine ISOPTO HYOSCINE brand 1Oralacetazolamide 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 brand 2 0.1%brimonidine ALPHAGAN P generic 1 0.15%brimonidine ALPHAGAN generic 1 0.2%Immunologic Agentslifitegrast XIIDRA brand 2 PAInfectionsBacterialbacitracin generic 1ciprofloxacin CILOXAN generic 1 solutionciprofloxacin CILOXAN brand 2 ointmenterythromycin ERYTHROMYCIN generic 1gentamicin 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 1

39




Miscellaneouscysteamine 0.44%

ophthalmic solution CYSTARAN brand 2 Diagnosis Required, QL, SP

sodium chloride hypertonic MURO 128 generic 1 soln 5%

Psychiatric

Insomniadoxylamine succinate UNISOM generic 1 25mg, OTC, QLNarcotic Antagonistnaloxone NARCAN NASAL SPRAY brand 2Miscellaneous dextromethorphan/

quinidine NUEDEXTA brand 2 Diagnosis Required, QL

guanfacine ER INTUNIV generic 1

PA, For recipients 6 – 17 years old, Intuniv is

part of the mental health formulary and billed fee-

for-service.For individuals not in this age range, Intuniv continues to be part

of the MCO pharmacy benefit.

Respiratory Drugs

Antitussives, 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

40




chlorphen tan/pyrilamine tan/PE tan

TRIOTANN PEDIATRIC SUSP

R-TANNAMINEgeneric 1 susp

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

41




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

dextromethorphan/ guaifenesin

GG/DM CRMUCINEX DMROBITUSSIN DMTUSSIN DM

generic 1 OTC

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

42




phenylephrine/ brompheniramine/ dextromethorphan

generic 1 OTC

phenylephrine/ chlorpheniramine/ dextromethorphan

RONDEC DMSTATUSS DM SYPCARDEC DM SYPMINUTUSS DR SYP

generic 1 syrup

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

promethazine & phenylephrine

PROMETH 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

43




pseudoephedrine/ dextromethorphan/guaifenesin

MULTI SYMPTOM TAB COLD RLF generic 1

pseudoephedrine/ iburprofen

CHILD IBUPRO SUS COLD

IBUOROFEN TAB COLD/SIN

generic 1

pseudoephedrine tan/ dexchlorphen tan/ DM tan

TANAFED DMX SUSPENSION

TRI-FED Xgeneric 1 susp

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 ASMANEX HFA brand 2Patients 8 years and

older will require prior authorization

Inhalers - Corticosteroid/Beta Agonist Combinationsfluticasone/salmeterol AIRDUO RESPICLICK generic 1 QLfluticasone/vilanterol BREO ELLIPTA brand 2 STInhalers - Othersipratropium/albuterol COMBIVENT RESPIMAT brand 2 inhaleripratropium HFA ATROVENT HFA brand 2omalizumab XOLAIR brand 2 PA, SPtiotropium/olodaterol STIOLTO RESPIMAT brand 2 QLumeclidinium inhalation INCRUSE ELLIPTA brand 2

44




Inhalers for Nebulization

albuterol ACCUNEB generic 1

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

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

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

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

authorization. QLcromolyn INTAL generic 1 soln, QLipratropium ATROVENT generic 1 soln, QLipratropium/albuterol DUONEB generic 1 solnlevalbuterol HCl XOPENEX RESPULES generic 1 QL, STOral Agents - Beta Agonistsmetaproterenol 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 1hyoscyamine,

methenamine, phenyl salicylate, sodium phosphate monobasic, methylene blue

UTIRA C brand 2

45




methenamine hippurateHIPREXUREX

generic 1

oxybutynin chloride DITROPAN XL generic 1 QLoxybutynin IR DITROPAN generic 1

oxybutynin patch OXYTROL FOR WOMEN OTC PATCH brand 2

pentosan polysulfate sodium ELMIRON brand 2 Diagnosis Required, QL

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

Vitamins and Mineralsb-complex B-COMPLEX VITAMIN TAB generic 1 OTC, QLcalcitriol ROCALTROL generic 1

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

authorization.calcium OS-CAL generic 1 OTCcalcium carb-vit D w/

minerals CALTRATE W/D generic 1 QL, OTC

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

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

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

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



cyanocobalamin VITAMIN B-12 generic 1 injelectrolyte PEDIALYTE generic 1 soln, oral, OTCergocalciferol (D2) DRISDOL generic 1ferrous sulfate FEOSOL generic 1 OTC

46




fluoride

GEL-KAMLURIDE LURIDE LOZI-TABSPREVIDENTPHOS-FLUR

generic 1

folic acid FOLIC ACID generic 1magnesium oxide MAG-OX generic 1 OTCmultivitamins/

fluoride/±iron POLY-VI-FLOR generic 1

multivitamins/minerals CENTRUM generic 1 OTCphytonadione MEPHYTON brand 2prenat-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

GENTEX ADE 28-1 MG brand 2


VINATE AZ EX brand 2


VINATE II brand 2

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

47




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

prenatal vit w/o vit a w/fe bisglycinate-fa tab 32-1 mg

brand 2

prenatal vitamins w/folic acid

PRENATAL VITAMINS W/ FOLIC ACID

MATERNANESTABS

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 OTC

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

zinc generic 1 OTCPotassiumphosphorus K-PHOS NEUTRAL generic 1 tabspotassium acid phosphate K-PHOS ORIGINAL brand 2potassium bicarbonate/

potassium citrate effervescent

K-LYTE generic 1 tabs

potassium chloride K-LOR generic 1 powderpotassium chloride POTASSIUM CHLORIDE generic 1 liquid

potassium chloride extended-release

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

generic 1 tabs

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

48




Miscellaneous

Anaphylaxis

epinephrineEPIPEN EPIPEN JR.

generic 1 QL

Antidotesacetylcysteine CETYLEV brand 2succimer CHEMET brand 2 QLCystic Fibrosisacetylcysteine MUCOMYST generic 1

aztreonam CAYSTON brand 2 Diagnosis Required, QL, SP

dornase alfa PULMOZYME brand 2 Diagnosis Required, QL, 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, QL, SP

Hereditary Angioedemac1 esterase inhibitor,

humanBERINERTHAEGARDA

brand 2 PA, 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

49




Metabolic Modifierscarglumic acid CARBAGLU brand 2 PA, SPglycerol phenylbutyrate RAVICTI brand 2 PA, SP

sodium phenylbutyrate BUPHENYL generic 1 Diagnosis Required, QL, SP

Vaccinediphtheria-tetanus tox

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

hepatitis a vaccine suspHAVRIXVAQTA

brand 2 QL

hepatitis b vaccine (recombinant)

ENGERIX-BRECOMBIVAX HB

brand 2 QL

hepatitis b vaccine recombinant adjuvanted

HEPLISAV-B brand 2 QL

human papillomavirus (hpv) 9-valent recomb vac

GARDASIL 9 brand 2 QL

human papillomavirus (hpv) quadrivalent recombinant vac

GARDASIL brand 2 QL

influenza virus vaccine recombinant hemagglutinin (ha)

FLUBLOK brand 2 QL

influenza virus vaccine split

AFLURIAFLUZONE SPLT

brand 2 QL

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

influenza virus vaccine split pf AFLURIA PF brand 2 QL

influenza virus vaccine split quadrivalent

FLUARIX QUADFLULAVAL QUADFLUZONE QUAD

brand 2 QL

influenza virus vaccine tiss-cult subunit FLUCELVAX brand 2 QL

influenza virus vaccine types a&b surface antigen

FLUVIRIN brand 2 QL

50




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-diphtheria toxoids (td)

TENIVACTET/DIP TOX INJ

brand 2 QL

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

typhoid vaccine VIVOTIF BERNA brand 2 capsulesvaricella virus vac live for

subcutaneous VARIVAX brand 2 QL

zoster vaccine live ZOSTAVAX brand 2 Age Limits Apply, QLzoster vaccine

recombinant adjuvanted

SHINGRIX brand 2 Age Limits Apply, QL

51



Generic Drug Name Brand Drug Name Examples

OTC MEDICATIONS

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

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

miconazole crm

tolnaftate

MICATINLOTRIMIN AFTINACTIN

vaginal productsMONISTATGYNE-LOTRIMIN

Antiviralsdocosanol ABREVA OTC CREAMAtopic Dermatitis

emollients

BETACARE CREAM AND LOTIONCETAPHIL CREAM AND LOTIONDERMAPHOR OINTMENTE-OINTMENTGLYCERIN TOPICAL

Cough/Cold AllergyAntihistamines

antihistamines

CHLOR-TRIMETONBENADRYLCLARITINALAVERTZYRTEC

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

loratadine/pseudoephedrineALAVERT ALRG TAB/SINUSALAVERT D ALLERGY/CONG

52




Cough/Cold

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

ROBITUSSINROBITUSSIN DMROBITUSSIN PEROBITUSSIN CFDELSYM

nasal spraysNEO-SYNEPHRINEAFRINDIMETAPP DRO DECONGES

Diabetesalcohol swabs CURITY ALCOHOL PADSglucose oral tablets

insulin (vials only) HUMULINNOVOLIN

Earwax Removal Productscarbamide peroxide DEBROXFamily Planning

condoms - male

TROJANKIMONOLIFESTYLESTRUSTEXDUREXFANTASY

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

topical antibacterialsNEOSPORINBACITRACIN

Gastrointestinal

antacids liquids, chew tabsMYLANTA LIQUIDMAALOX LIQUIDTUMS

53




antidiarrhealsIMODIUM A-DKAOPECTATE

electrolyte rehydrating soln PEDIALYTEfamotidine PEPCID AClaxative enemas FLEET ENEMA

laxativesDULCOLAXFLEET PHOSPHO-SODA

probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

psyllium METAMUCILrectal crm, suppositories PREPARATION Hsimethicone MYLICONstool softeners COLACEsugar+orthophosphoric acid EMETROLInsomniadoxylamine succinate UNISOMLice Productspermethrin NIXpyrethrins/piperonyl butoxide liquid shampoo RID SHAMPOOMotion Sicknessdimenhydrinate DRAMAMINEmeclizine BONINEOphthalmicsallergic conjunctivitis ALAWAYartificial tears HYPOTEARS

54




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, dropsADVILMOTRIN IB

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

calcium

CALTRATECALTRATE W/DOS-CALTUMS

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

FERGONFEOSOL

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

vitamins pediatric members <3 years oldPOLY-VI-SOLTRI-VI-SOLVI-DAYLIN

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

55

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

Index of Covered Drugs

Aabaloparatide inj . . . . . . . . . . . 24abemaciclib . . . . . . . . . . . . . . . . 4abiraterone . . . . . . . . . . . . . . . . . 5ABREVA OTC CREAM . . .31, 51ABSORICA . . . . . . . . . . . . . . . 16acalabrutinib . . . . . . . . . . . . . . . 4acarbose . . . . . . . . . . . . . . . . . 23ACCUHIST DROPS . . . . . . . . 39ACCUNEB . . . . . . . . . . . . . . . . 44ACCUPRIL . . . . . . . . . . . . . . . . . 8ACCURETIC . . . . . . . . . . . . . . . 8acebutolol . . . . . . . . . . . . . . . . . 9acetaminophen

. . . . . . . . 13, 14, 32, 42, 54acetaminophen tabs, liquid,

drops, suppositories, chew tabs . . . . . . . . . . . . . . . . . . . 54

acetazolamide . . . . . . . . . . . . . 38acetazolamide

extended-release . . . . . . . 38acetic acid . . . . . . . . . . . . . . . . 20acetic acid/aluminum

acetate . . . . . . . . . . . . . . . . 20acetic acid/hydrocortisone . . 20acetylcysteine . . . . . . . . . . . . . 48acidophilus . . . . . . . . . . . . . . . 27ACIDOPHILUS XTRA . . . . . . . 27acidophilus/bifidus . . . . . . . . . 27ACIDOPHILUS/BIFIDUS

WAFER . . . . . . . . . . . . . . . . 27acidophilus/citrus pectin . . . . 27acidophilus/pectin . . . . . . . . . 27acitretin . . . . . . . . . . . . . . . . . . . 18ACLOVATE . . . . . . . . . . . . . . . . 17ACTIFED . . . . . . . . . . . . . .21, 51ACTIGALL . . . . . . . . . . . . . . . . 28ACTIMMUNE . . . . . . . . . . . . . . . 6ACTOS . . . . . . . . . . . . . . . . . . . 24ACULAR/ACULAR LS . . . . . . 36acyclovir . . . . . . . . . . . . . . . . . . 31ADACEL . . . . . . . . . . . . . . . . . . 50ADALAT CC . . . . . . . . . . . . . . . 10adalimumab . . . . . . . . . . . . . . . 32adapalene gel . . . . . . . . . .16, 51

ADEMPAS . . . . . . . . . . . . . . . . 12ADLYXIN . . . . . . . . . . . . . . . . . 24ADMELOG SOLOSTAR . . . . . 23ADMELOG VIALS . . . . . . . . . . 23ADVIL . . . . . . . . . . . . . 13, 33, 54afatinib . . . . . . . . . . . . . . . . . . . . 4AFINITOR . . . . . . . . . . . . . . . . . . 4AFINITOR DISPERZ . . . . . . . . . 4AFLURIA . . . . . . . . . . . . . . . . . 49AFLURIA PF . . . . . . . . . . . . . . . 49AFRIN . . . . . . . . . . . . . . . . .21, 52AGRYLIN . . . . . . . . . . . . . . . . . . 7AIRDUO RESPICLICK . . . . . . 43ALAVERT . . . . . . . . . . 20, 21, 51ALAVERT ALRG TAB/

SINUS . . . . . . . . . . . . . .21, 51ALAVERT D . . . . . . . . . . . . . . . 51ALAVERT-D . . . . . . . . . . . . . . . 21ALAWAY . . . . . . . . . . . . . . .36, 53ALAWAY OTC . . . . . . . . . . . . . 36albendazole . . . . . . . . . . . . . . . 28ALBENZA . . . . . . . . . . . . . . . . 28albiglutide . . . . . . . . . . . . . . . . 24albuterol . . . . . . . . . . . . . . .43, 44albuterol sulfate . . . . . . . . . . . . 43alclometasone . . . . . . . . . . . . . 17alcohol swabs . . . . . . . . . . . . . 52ALDACTAZIDE . . . . . . . . . . . . 10ALDACTONE . . . . . . . . . . . . . . 10ALDARA . . . . . . . . . . . . . . . . . . 19ALDOMET . . . . . . . . . . . . . . . . 12ALDORIL . . . . . . . . . . . . . . . . . 12ALECENSA . . . . . . . . . . . . . . . . 4alectinib . . . . . . . . . . . . . . . . . . . 4alendronate . . . . . . . . . . . . . . . 24ALESSE . . . . . . . . . . . . . . . . . . 34alfuzosin ER . . . . . . . . . . . . . . . 44alginic acid/sodium

bicarbonate . . . . . . . . . . . . 26ALIGN . . . . . . . . . . . . . . . . .28, 53ALINIA . . . . . . . . . . . . . . . . . . . 30ALINIA SUSPENSION . . . . . . 30alirocumab . . . . . . . . . . . . . . . . 11alitretinoin 1% gel . . . . . . . . . . . 6ALKERAN . . . . . . . . . . . . . . . . . 4allergic conjunctivitis . . . . . . . 53

ALLERGY/CONG . . . . . . .21, 51allopurinol . . . . . . . . . . . . . . . . 33alogliptin . . . . . . . . . . . . . . . . . . 23alogliptin/metformin . . . . . . . . 23alogliptin/pioglitazone . . . . . . 23ALPHAGAN . . . . . . . . . . . . . . . 38ALPHAGAN P . . . . . . . . . . . . . 38ALTACE . . . . . . . . . . . . . . . . . . . 8altretamine . . . . . . . . . . . . . . . . . 4alumina/magnesia . . . . . . . . . 26alumina/magnesia/

simethicone . . . . . . . . . . . . 26aluminum acetate . . . . . . .19, 20aluminum chloride topical

solution . . . . . . . . . . . . . . . 19ALUNBRIG . . . . . . . . . . . . . . . . . 4amantadine . . . . . . . . . . . .15, 31AMARYL . . . . . . . . . . . . . . . . . 23ambrisentan . . . . . . . . . . . . . . . 12AMERGE . . . . . . . . . . . . . . . . . 15AMICAR . . . . . . . . . . . . . . . . . . . 7amiloride . . . . . . . . . . . . . . . . . 10amiloride/

hydrochlorothiazide . . . . . 10aminocaproic acid . . . . . . . . . . 7aminosalicyclic acid . . . . . . . . 28amiodarone tabs . . . . . . . . . . . . 9amlodipine . . . . . . . . . . . . . . . . . 9ammonium lactate . . . . . . . . . 19AMNESTEEM . . . . . . . . . . . . . 16amoxicillin . . . . . . . . . . . . .29, 30AMOXICILLIN CAPSULES AND

CHEWABLES . . . . . . . . . . 29amoxicillin/clavulanate . . . . . . 30AMOXIL SUSP. . . . . . . . . . . . . 29ampicillin . . . . . . . . . . . . . . . . . 30anagrelide . . . . . . . . . . . . . . . . . 7anakinra . . . . . . . . . . . . . . . . . . 32anastrozole. . . . . . . . . . . . . . . . . 5antacids liquids, chew tabs . . 52antidiarrheals . . . . . . . . . . . . . . 53antihistamines . . . . . . . . . .20, 51antitussives . . . . . . . . . 3, 39, 52ANTIVERT . . . . . . . . . . . . . . . . 25ANUSOL HC 2.5% . . . . . . . . . 19APHEDRID TAB . . . . . . . . . . . 43

56


Index of Covered Drugsapixaban . . . . . . . . . . . . . . . . . . 7apremilast . . . . . . . . . . . . . . . . 32aprepitant . . . . . . . . . . . . . . . . . 25APRESOLINE . . . . . . . . . . . . . 12APRISO . . . . . . . . . . . . . . . . . . 27ARALEN . . . . . . . . . . . . . . . . . . 31ARANESP . . . . . . . . . . . . . . . . . 7ARAVA . . . . . . . . . . . . . . . . . . . 32ARCAPTA NEOHALER . . . . . 43ARICEPT . . . . . . . . . . . . . . . . . 12ARIMIDEX . . . . . . . . . . . . . . . . . 5ARNUITY ELLIPTA . . . . . . . . . 43AROMASIN . . . . . . . . . . . . . . . . 5ARTANE . . . . . . . . . . . . . . . . . . 15artificial tears . . . . . . . . . . . . . . 53asfotase alfa . . . . . . . . . . . . . . . 24ASMANEX HFA . . . . . . . . . . . . 43aspirin . . . . . . . .7, 13, 14, 32, 54aspirin tabs, EC tabs, chew

tabs . . . . . . . . . . . . . . . . . . . 54aspirin with buffers tabs . . . . . 54aspirin/acetaminophen/

caffeine . . . . . . . . . . . . . . . 13ASTELIN. . . . . . . . . . . . . . . . . . 20ATABEX PRENATAL . . . . . . . . 47atenolol . . . . . . . . . . . . . . . . . . . . 9atenolol/chlorthalidone . . . . . . 9atorvastatin . . . . . . . . . . . . . . . 11atovaquone . . . . . . . . . . . . . . . 30atropine . . . . . . . . . . . 25, 28, 38atropine sulfate . . . . . . . . . . . . 28ATROVENT . . . . . . . . 21, 43, 44ATROVENT HFA . . . . . . . . . . . 43ATROVENT NASAL SPRAY . 21AUBAGIO . . . . . . . . . . . . . . . . . 15AUGMENTIN . . . . . . . . . . . . . . 30auranofin . . . . . . . . . . . . . . . . . 32AVITA . . . . . . . . . . . . . . . . . . . . 16axitinib . . . . . . . . . . . . . . . . . . . . 4AYGESTIN . . . . . . . . . . . . . . . . 35azathioprine . . . . . . . . . . . . . 6, 32azelaic acid . . . . . . . . . . . . . . . 16azelastine . . . . . . . . . . . . . .20, 36azithromycin . . . . . . . . . . . . . . 29aztreonam . . . . . . . . . . . . . . . . 48AZULFIDINE . . . . . . . . . . .27, 32

AZULFIDINE EN-TABS . . .27, 32

Bb-complex . . . . . . . . . . . . .45, 54B-COMPLEX VITAMIN TAB . .45,

54BACID . . . . . . . . . . . . . . . . .28, 53bacitracin . . . . . . . 16, 37, 38, 52bacitracin/polymyxin/

neomycin/hc . . . . . . . . . . . 37baclofen . . . . . . . . . . . . . . . . . . 33BACTRIM . . . . . . . . . . . . . . . . . 30BACTRIM DS . . . . . . . . . . . . . . 30BACTROBAN . . . . . . . . . . . . . 16balsalazide . . . . . . . . . . . . . . . . 27BALZIVA . . . . . . . . . . . . . . . . . . 34BARACLUDE . . . . . . . . . . . . . . 31BASAGLAR . . . . . . . . . . . . . . . 22BAYER . . . . . . . . . . . . . 7, 32, 54becaplermin gel . . . . . . . . . . . 19beclomethasone . . . . . . . . . . . 43bedaquiline . . . . . . . . . . . . . . . 31BENADRYL . . . . . . . . . . . .20, 51benazepril . . . . . . . . . . . . . . . . . 8benazepril/

hydrochlorothiazide . . . . . . 8BENTYL . . . . . . . . . . . . . . . . . . 27BENZAC AC . . . . . . . . . . . . . . 16benznidazole . . . . . . . . . . . . . . 30benzocaine/antipyrine . . . . . . 20benzonatate . . . . . . . . . . . . . . . 39BENZOTIC . . . . . . . . . . . . . . . . 20benzoyl peroxide . . . . . . . .16, 51benzoyl peroxide crm, gel,

lotion . . . . . . . . . . . . . . . . . . 51benztropine . . . . . . . . . . . . . . . 15BERINERT . . . . . . . . . . . . . . . . 48BETA-VAL . . . . . . . . . . . . . . . . 17BETACARE CREAM AND

LOTION . . . . . . . . . . . . . . . 51BETAGAN . . . . . . . . . . . . . . . . 37betamethasone augmented

dip . . . . . . . . . . . . . . . . . . . . 17betamethasone dip

augmented . . . . . . . . . . . . 17betamethasone dipropionate 17

betamethasone val . . . . . . . . . 17BETAPACE . . . . . . . . . . . . . . . . 9BETAPACE AF . . . . . . . . . . . . . . 9betaxolol . . . . . . . . . . . . . . . . . . . 9bethanechol . . . . . . . . . . . . . . . 44BETHKIS . . . . . . . . . . . . . . . . . 48betrixaban . . . . . . . . . . . . . . . . . 7BEVYXXA . . . . . . . . . . . . . . . . . 7bexarotene caps and

topical gel . . . . . . . . . . . . . . 6BIAXIN . . . . . . . . . . . . . . . . . . . 29BIAXIN XL . . . . . . . . . . . . . . . . 29bicalutamide . . . . . . . . . . . . . . . 5BICITRA . . . . . . . . . . . . . . . . . . 45BILTRICIDE . . . . . . . . . . . . . . . 28BIO-D DRO-MULSION . . . . . . 45BIO-D-MULSIO DRO FORTE 45BIOGAIA . . . . . . . . . . . . . . .28, 53bisoprolol . . . . . . . . . . . . . . . . . . 9bisoprolol/

hydrochlorothiazide . . . . . . 9BLEPH-10 . . . . . . . . . . . . . . . . 38BONINE . . . . . . . . . . . . . . . . . . 53BOOSTRIX . . . . . . . . . . . . . . . . 50bosentan . . . . . . . . . . . . . . . . . 12BOSULIF . . . . . . . . . . . . . . . . . . 4bosutinib . . . . . . . . . . . . . . . . . . 4BREO ELLIPTA . . . . . . . . . . . . 43BRETHINE . . . . . . . . . . . . . . . . 44brigatinib . . . . . . . . . . . . . . . . . . 4BRILINTA . . . . . . . . . . . . . . . . . . 7brimonidine . . . . . . . . . . . .18, 38BROMETANE DX . . . . . . . . . . 40BROMFED DM . . . . . . . . . . . . 39brompheniramine &

phenylephrine . . . . . . . . . . 39brompheniramine/

pseudoephedrine 39, 40, 51brompheniramine/

pseudoephedrine/dextromethorphan . . . . . . 39

budesonide . . . . . . . . . . . .27, 44bumetanide . . . . . . . . . . . . . . . 10BUMEX . . . . . . . . . . . . . . . . . . . 10BUPHENYL . . . . . . . . . . . . . . . 49Burow’s soln, wet dressings . 52

57



busulfan . . . . . . . . . . . . . . . . . . . 4butalbital/acetaminophen . . . 13butalbital/acetaminophen/

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

Cc1 esterase inhibitor, human . 48cabergoline . . . . . . . . . . . . . . . 24CABOMETYX . . . . . . . . . . . . . . 4cabozantinib . . . . . . . . . . . . . . . 4CAFERGOT . . . . . . . . . . . . . . . 14calamine . . . . . . . . . . . . . . . . . . 19CALAN . . . . . . . . . . . . . . . .10, 15CALAN SR . . . . . . . . . . . . . . . . 10calcipotriene . . . . . . . . . . . . . . 18calcitonin-salmon . . . . . . . . . . 24calcitriol . . . . . . . . . . . . . . .18, 45calcitriol oral soln . . . . . . . . . . 45calcium . . . . 2, 9, 25, 45, 48, 54calcium acetate . . . . . . . . . . . . 48calcium carb-vit D

w/ minerals . . . . . . . . . . . . 45CALQUENCE . . . . . . . . . . . . . . 4CALTRATE . . . . . . . . . . . . .45, 54CALTRATE W/D . . . . . . . .45, 54canakinumab . . . . . . . . . . . . . 32CANASA. . . . . . . . . . . . . . . . . . 27capecitabine . . . . . . . . . . . . . . . 4CAPOTEN . . . . . . . . . . . . . . . . . 8CAPOZIDE . . . . . . . . . . . . . . . . . 8CAPRELSA . . . . . . . . . . . . . . . . 5CAPSAGEL . . . . . . . . . . . . . . . 32capsaicin . . . . . . . . . . . . . . . . . 32captopril . . . . . . . . . . . . . . . . . . . 8captopril/hydrochlorothiazide . 8CAPZASIN-P . . . . . . . . . . . . . . 32CARAFATE . . . . . . . . . . . . . . . . 26CARAFATE SUSPENSION . . 26CARBAGLU . . . . . . . . . . . . . . . 49carbamide peroxide . . . . .20, 52carbidopa/levodopa . . . . . . . . 15

carbidopa/levodopa extended-release . . . . . . . . . . . . . . . . 15

CARDEC DM DRO . . . . . . . . . 42CARDEC DM SYP . . . . . . . . . 42CARDEC DRO . . . . . . . . . . . . . 40CARDEC SYP . . . . . . . . . . . . . 40CARDENE . . . . . . . . . . . . . . . . . 9CARDIZEM . . . . . . . . . . . . . . . 10CARDIZEM CD . . . . . . . . . . . . 10CARDIZEM SR . . . . . . . . . . . . 10CARDURA . . . . . . . . . . . . . . 8, 44carglumic acid . . . . . . . . . . . . . 49carteolol . . . . . . . . . . . . . . . . . . 37carvedilol . . . . . . . . . . . . . . . . . . 9casanthranol-docusate

sodium . . . . . . . . . . . . . . . . 25CASODEX . . . . . . . . . . . . . . . . . 5CASTIVA . . . . . . . . . . . . . . . . . 32CATAFLAM . . . . . . . . . . . .13, 32CATAPRES . . . . . . . . . . . . . . . . . 8CAYSTON . . . . . . . . . . . . . . . . 48CECLOR . . . . . . . . . . . . . . . . . 29cefaclor . . . . . . . . . . . . . . . . . . . 29cefadroxil . . . . . . . . . . . . . . . . . 29cefdinir . . . . . . . . . . . . . . . . . . . 29cefixime . . . . . . . . . . . . . . . . . . 29cefprozil . . . . . . . . . . . . . . . . . . 29CEFTIN . . . . . . . . . . . . . . . . . . . 29cefuroxime axetil . . . . . . . . . . . 29CEFZIL . . . . . . . . . . . . . . . . . . . 29CELEBREX . . . . . . . . . . . . . . . 32celecoxib . . . . . . . . . . . . . . . . . 32CELLCEPT . . . . . . . . . . . . . . . . . 6CENTRUM . . . . . . . . . . . . . . . . 46cephalexin . . . . . . . . . . . . . . . . 29ceritinib . . . . . . . . . . . . . . . . . . . . 4certolizumab . . . . . . . . . . . . . . 32CETAPHIL CREAM AND

LOTION . . . . . . . . . . . . . . . 51cetirizine . . . . . . . . . . . 20, 21, 51cetirizine chew tab . . . . . . . . . 20cetirizine hydrochloride/

pseudoephedrine hydrochloride 12 hours extended-release . . . . . . . 21

cetirizine/pseudoephedrine OTC . . . . . . . . . . . . . . . . . . 51

CETYLEV . . . . . . . . . . . . . . . . . 48CHEMET . . . . . . . . . . . . . . . . . 48CHILD IBUPRO SUS COLD . 43CHLOR-TRIMETON . . . . .20, 51CHLOR-TRIMETON

ALLERGY . . . . . . . . . . . . . 20CHLOR-TRIMETON SYRUP . 20chlorambucil . . . . . . . . . . . . . . . 4chlorhexidine gluconate. . . . . 21chloroquine phosphate . . . . . 31chlorothiazide . . . . . . . . . . . . . 10chlorphen tan/carbetapentane

tan . . . . . . . . . . . . . . . . . . . . 39chlorphen tan/pyrilamine tan/

PE tan . . . . . . . . . . . . . . . . . 40chlorpheniramine extended-

release . . . . . . . . . . . . . . . . 20chlorpheniramine

maleate . . . . . . . . . . . .20, 40chlorpheniramine maleate

phenylephrine HCL . . . . . 40chlorpheniramine tan/

phenylephrine tan. . . . . . . 40chlorpheniramine/

dextromethorphan . . .40, 42chlorpheniramine/

phenylephrine . . . . . . .21, 40chlorpheniramine/

phenylephrine/pyrilamine 21chlorpheniramine/

pseudoephedrine 21, 40, 51chlorpropamide. . . . . . . . . . . . 23chlorthalidone . . . . . . . . . . . 9, 10chlorzoxazone . . . . . . . . . . . . . 33CHOLBAM . . . . . . . . . . . . . . . . 24cholecalciferol . . . . . . . . . . . . . 45cholestyramine . . . . . . . . . . . . 11cholic acid . . . . . . . . . . . . . . . . 24choriogonadotropin alfa . . . . . 36chorionic gonadotropin . . . . . 36ciclopirox . . . . . . . . . . . . . . . . . 18cilostazol . . . . . . . . . . . . . . . . . . 7CILOXAN . . . . . . . . . . . . . . . . . 38cimetidine . . . . . . . . . . . . . . . . 26

58


Index of Covered DrugsCIMZIA . . . . . . . . . . . . . . . . . . . 32cinacalcet . . . . . . . . . . . . . . . . . 48CIPRO . . . . . . . . . . . . . . . . . . . 29CIPRODEX . . . . . . . . . . . . . . . . 20ciprofloxacin . . . . . . . 20, 29, 38ciprofloxacin/dexamethasone 20CLARAVIS . . . . . . . . . . . . . . . . 16clarithromycin . . . . . . . . . . . . . 29clarithromycin ER . . . . . . . . . . 29CLARITIN . . . . . . . . . . . . . .20, 51CLARITIN-D . . . . . . . . . . . . . . . 41CLEAR EYES REDNESS

RELIEF . . . . . . . . . . . . . . . . 36CLEARASIL . . . . . . . . . . . . . . . 51clemastine . . . . . . . . . . . . . . . . 20CLEOCIN . . . . . . . . . . 16, 31, 36CLEOCIN T . . . . . . . . . . . . . . . 16CLIMARA . . . . . . . . . . . . . . . . . 35clindamycin . . . . . . . . 16, 31, 36CLINORIL . . . . . . . . . . . . . .13, 33clobetasol propionate. . . . . . . 17clonidine. . . . . . . . . . . . . . . . . . . 8clopidogrel . . . . . . . . . . . . . . . . . 7clotrimazole . . . . . 18, 30, 36, 51clotrimazole with

betamethasone . . . . . . . . . 18cobimetinib . . . . . . . . . . . . . . . . 4codeine sulfate . . . . . . . . . . . . 14codeine/acetaminophen . . . . 14codeine/chlorpheniramine/

pseudoephedrine . . . . . . . 40codeine/guaifenesin. . . . . . . . 40codeine/guaifenesin/

pseudoephedrine . . . . . . . 40codeine/promethazine. . . . . . 40codeine/promethazine/

phenylephrine . . . . . . . . . . 40CODIMAL DH . . . . . . . . . . . . . 42COGENTIN . . . . . . . . . . . . . . . 15COLACE . . . . . . . . . . . . . .25, 53COLAZAL . . . . . . . . . . . . . . . . 27colchicine . . . . . . . . . . . . . . . . . 33collagenase oint . . . . . . . . . . . 19COLLOIDAL OATMEAL

BATHS . . . . . . . . . . . . . . . . 52COLOCORT. . . . . . . . . . . . . . . 27

COLYTE . . . . . . . . . . . . . . . . . . 25COMBIVENT RESPIMAT . . . . 43COMETRIQ . . . . . . . . . . . . . . . . 4COMPAZINE . . . . . . . . . . . . . . 26COMPLETE NATALCARE

PAK DHA . . . . . . . . . . . . . . 46COMTAN . . . . . . . . . . . . . . . . . 15condoms - male . . . . . . . . . . . 52CONDYLOX SOL . . . . . . . . . . 18conjugated estrogen/

bazedoxifene . . . . . . . . . . . 36contraceptive foam . . . . . . . . . 52contraceptive gel . . . . . . . . . . . 52COPAXONE . . . . . . . . . . . . . . . 15CORDARONE . . . . . . . . . . . . . . 9COREG . . . . . . . . . . . . . . . . . . . 9CORICIDIN TAB CGH/CLD . . 40CORTAID . . . . . . . . . . . . . . . . . 52CORTEF . . . . . . . . . . . . . . . . . . 22cortisone acetate . . . . . . . . . . 22CORTISPORIN . . . . . . . . .20, 37CORTISPORIN OTIC . . . . . . . 20CORTIZONE . . . . . . . . . . . . . . 17CORTIZONE-10 INTENSIVE

HEALING . . . . . . . . . . . . . . 17COSENTYX . . . . . . . . . . . . . . . 32COSOPT . . . . . . . . . . . . . . . . . 37COTELLIC . . . . . . . . . . . . . . . . . 4COUMADIN . . . . . . . . . . . . . . . . 7COZAAR . . . . . . . . . . . . . . . . . . 8CREON . . . . . . . . . . . . . . . . . . . 27CREON 3000 UNIT . . . . . . . . 27crisaborole . . . . . . . . . . . . . . . . 19crizotinib . . . . . . . . . . . . . . . . . . . 4crofelemer . . . . . . . . . . . . . . . . 25CROLOM . . . . . . . . . . . . . . . . . 36cromolyn . . . . . . . . . . 21, 36, 44cromolyn sodium . . . . . . .21, 36crotamiton . . . . . . . . . . . . . . . . 18CULTURELLE . . . . . . . . . .28, 53CURITY ALCOHOL PADS . . . 52CUTIVATE . . . . . . . . . . . . . . . . 17cyanocobalamin . . . . . . . . . . . 45CYCLESSA . . . . . . . . . . . . . . . 35cyclobenzaprine . . . . . . . . . . . 33CYCLOGYL . . . . . . . . . . . . . . . 38

cyclopentolate . . . . . . . . . . . . . 38cyclophosphamide . . . . . . . . . . 4cycloserine . . . . . . . . . . . . . . . . 28cyclosporine . . . . . . . . . . . . . . . 6cyclosporine, modified . . . . . . . 6cyproheptadine . . . . . . . . . . . . 20CYSTAGON . . . . . . . . . . . . . . . . 6CYSTARAN . . . . . . . . . . . . . . . 39cysteamine 0.44% ophthalmic

solution . . . . . . . . . . . . . . . 39cysteamine bitartrate . . . . . . . . 6CYTOMEL . . . . . . . . . . . . . . . . 24CYTOTEC . . . . . . . . . . . . . . . . 28CYTOVENE . . . . . . . . . . . . . . . 30CYTOXAN . . . . . . . . . . . . . . . . . 4

DD3-50 CAP . . . . . . . . . . . . . . . . 45D.H.E. 45 . . . . . . . . . . . . . . . . . 14dabrafenib . . . . . . . . . . . . . . . . . 4daclizumab . . . . . . . . . . . . . . . 15danazol . . . . . . . . . . . . . . . . . . . 35DANOCRINE . . . . . . . . . . . . . . 35DANTRIUM . . . . . . . . . . . . . . . 33dantrolene . . . . . . . . . . . . . . . . 33dapsone . . . . . . . . . . . . . . . . . . 31DARAPRIM . . . . . . . . . . . . . . . 32darbepoetin alfa . . . . . . . . . . . . 7dasatinib . . . . . . . . . . . . . . . . . . . 4DAYPRO . . . . . . . . . . . . . . .13, 33DDAVP . . . . . . . . . . . . . . . . . . . 24DEBROX . . . . . . . . . . . . . .20, 52DECADRON . . . . . . . . . . . . . . 22decongestants . . . 3, 21, 39, 54deferasirox . . . . . . . . . . . . . . . . . 7DELATESTRYL . . . . . . . . . . . . 22DELFEN . . . . . . . . . . . . . . . . . . 52DELSYM . . . . . . . . . . . . . . .41, 52DELTASONE . . . . . . . . . . . . . . 22DELZICOL . . . . . . . . . . . . . . . . 27DEMADEX . . . . . . . . . . . . . . . . 10DEMEROL . . . . . . . . . . . . . . . . 14DEPEN TITRATABLE . . . . . . . 32DEPO-PROVERA . . . . . . . . . . 34DEPO-TESTOSTERONE . . . . 22DERMA-SMOOTHE OIL/FS . 17

59



DERMAPHOR OINTMENT . . 51dermatological baths . . . . . . . 52DERMATOP . . . . . . . . . . . . . . . 17DESENEX . . . . . . . . . . . . . . . . 18desmopressin . . . . . . . . . . . . . 24desogestrel/EE . . . . . . . . .34, 35DETROL . . . . . . . . . . . . . . . . . . 45dexamethasone . . . . 20, 22, 37dexamethasone sodium

phosphate . . . . . . . . . . . . . 37DEXASOL . . . . . . . . . . . . . . . . 37dextromethorphan hbr . . . . . . 41dextromethorphan polistirex

extended-release . . . . . . . 41dextromethorphan-

guaifenesin . . . . . . . . . . . . 41dextromethorphan/

brompheniramine/pseudoephedrine . . . . . . . 40

dextromethorphan/ guaifenesin . . . . . . . . . 41-43

dextromethorphan/promethazine . . . . . . . . . . 41

dextromethorphan/quinidine 39DIABINESE . . . . . . . . . . . . . . . 23DIAMOX SEQUELS . . . . . . . . 38diclofenac 1% gel . . . . . . . . . . 32diclofenac potassium . . . .13, 32diclofenac sodium

. . . . . . . . . . . . 13, 32, 33, 36diclofenac sodium delayed-

release . . . . . . . . . . . . .13, 32diclofenac sodium extended-

release . . . . . . . . . . . . .13, 33dicloxacillin . . . . . . . . . . . . . . . 30dicyclomine . . . . . . . . . . . . . . . 27DIDRONEL. . . . . . . . . . . . . . . . 24DIFFERIN OTC GEL 0.1% 16, 51DIFICID . . . . . . . . . . . . . . . . . . . 29DIFLUCAN . . . . . . . . . . . . .30, 36DIGESTIVE PROBIOTIC .28, 53digoxin . . . . . . . . . . . . . . . . . . . . 9DIHISTINE DH . . . . . . . . . . . . . 40DIHYDRO-PE SYP . . . . . . . . . 42dihydroergotamine . . . . . . . . . 14DILACOR XR . . . . . . . . . . . . . . 10

DILANTIN . . . . . . . . . . . . . . . . . 15DILANTIN INFATABS . . . . . . . 15DILAUDID . . . . . . . . . . . . . . . . 14diltiazem . . . . . . . . . . . . . . . . . . 10diltiazem extended-release . . 10diltiazem sustained-release . . 10DIMEATAPP DRO

DECONGES . . . . . . . . . . . 21dimenhydrinate . . . . . . . . . . . . 53DIMETAPP . . 39, 40, 42, 51, 52DIMETAPP CLD ELX/

ALLERGY . . . . . . . . . . . . . 39DIMETAPP DRO DCON/

CGH . . . . . . . . . . . . . . . . . . 42DIMETAPP DRO

DECONGES . . . . . . . . . . . 52DIMETAPP SYP CGH/CLD . . 40dimethyl fumarate . . . . . . . . . . 15DIP/TET PED INJ . . . . . . . . . . 49DIPENTUM . . . . . . . . . . . . . . . 27diphenhydramine . . . . . . . . . . 20diphenoxylate/atropine . . . . . 25diphtheria-tetanus tox adsorbed

(dt) im . . . . . . . . . . . . . . . . . 49DIPROLENE . . . . . . . . . . . . . . 17DIPROLENE AF . . . . . . . . . . . 17dipyridamole . . . . . . . . . . . . . . . 7DISALCID . . . . . . . . . . . . . . . . . 33disopyramide . . . . . . . . . . . . . . . 9disopyramide

extended-release . . . . . . . . 9DITROPAN . . . . . . . . . . . . . . . . 45DITROPAN XL . . . . . . . . . . . . . 45DIURIL . . . . . . . . . . . . . . . . . . . 10DIURIL ORAL SUSPENSION 10docosanol . . . . . . . . . . . . .31, 51docusate calcium plus . . . . . . 25docusate potasssium . . . . . . . 25docusate sodium . . . . . . . . . . 25dofetilide. . . . . . . . . . . . . . . . . . . 9DOMEBORO . . . . . . . . . . .20, 52DOMEBORO OTIC . . . . . . . . . 20donepezil . . . . . . . . . . . . . . . . . 12dornase alfa . . . . . . . . . . . . . . . 48dorzolamide . . . . . . . . . . . . . . . 37dorzolamide/timolol maleate 37

DOSTINEX . . . . . . . . . . . . . . . . 24DOVONEX . . . . . . . . . . . . . . . . 18doxazosin . . . . . . . . . . . . . . . 8, 44doxycycline monohydrate . . . 30doxylamine succinate . . . .39, 53DRAMAMINE . . . . . . . . . . . . . 53DRISDOL . . . . . . . . . . . . . . . . . 45dronabinol . . . . . . . . . . . . . . . . 25DROXIA . . . . . . . . . . . . . . . . . . . 6DUAVEE . . . . . . . . . . . . . . . . . . 36dulaglutide . . . . . . . . . . . . . . . . 24DULCOLAX . . . . . . . . . . . . . . . 53DUOFILM . . . . . . . . . . . . . .18, 54DUONEB . . . . . . . . . . . . . . . . . 44DURAGESIC . . . . . . . . . . . . . . 14DURATUSS DM ELX . . . . . . . 41DUREX . . . . . . . . . . . . . . . . . . . 52DURICEF . . . . . . . . . . . . . . . . . 29DYAZIDE . . . . . . . . . . . . . . . . . 10

EE-OINTMENT . . . . . . . . . . . . . 51E.E.S. . . . . . . . . . . . . . . . . . . . . 29ecothiophate . . . . . . . . . . . . . . 37ECOTRIN . . . . . . . . . . . 7, 32, 54ED A-HIST TABLETS AND

LIQUID . . . . . . . . . . . . . . . . 40EDGE OB CHW . . . . . . . . . . . 46edoxaban . . . . . . . . . . . . . . . . . . 7EFFIENT . . . . . . . . . . . . . . . . . . . 7EFUDEX . . . . . . . . . . . . . . . . . . 19EGRIFTA . . . . . . . . . . . . . . . . . 24ELDEPRYL . . . . . . . . . . . . . . . . 15electrolyte . . . . . . . . . . . . . .45, 53electrolyte rehydrating soln . . 53ELIDEL . . . . . . . . . . . . . . . . . . . 19ELIMITE . . . . . . . . . . . . . . . . . . 18ELIQUIS . . . . . . . . . . . . . . . . . . . 7ELMIRON . . . . . . . . . . . . . . . . . 45ELOCON . . . . . . . . . . . . . . . . . 17eltrombopag . . . . . . . . . . . . . . 48EMCYT . . . . . . . . . . . . . . . . . . . . 4EMEND . . . . . . . . . . . . . . . . . . 25EMETROL . . . . . . . . . . . . . . . . 53emicizumab-kxwh . . . . . . . . . . . 7EMLA . . . . . . . . . . . . . . . . . . . . 19

60


Index of Covered Drugsemollients . . . . . . . . . . . . . . . . . 51enalapril . . . . . . . . . . . . . . . . . . . 8enalapril oral soln . . . . . . . . . . . 8enalapril/hydrochlorothiazide . 8ENBREL . . . . . . . . . . . . . . . . . . 32ENGERIX-B . . . . . . . . . . . . . . . 49enoxaparin . . . . . . . . . . . . . . . . . 7entacapone . . . . . . . . . . . . . . . 15entecavir . . . . . . . . . . . . . . . . . . 31ENTERIC COATED-

NAPROSYN . . . . . . . . .13, 33ENTOCORT EC . . . . . . . . . . . . 27ENTRESTO . . . . . . . . . . . . . . . . 9ENULOSE . . . . . . . . . . . . . . . . 25EPANED . . . . . . . . . . . . . . . . . . . 8epinephrine . . . . . . . . . . . . . . . 48EPIPEN . . . . . . . . . . . . . . . . . . . 48EPIPEN JR. . . . . . . . . . . . . . . . 48EPIVIR HBV . . . . . . . . . . . . . . . 31epoetin alfa . . . . . . . . . . . . . . . . 7EPOGEN . . . . . . . . . . . . . . . . . . 7ergocalciferol (D2) . . . . . . . . . 45ergotamine tartrate/caffeine . 14ergotamine/caffeine . . . . . . . . 14ERIVEDGE . . . . . . . . . . . . . . . . . 7erlotinib . . . . . . . . . . . . . . . . . . . 4ertugliflozin . . . . . . . . . . . . . . . 23ertugliflozin/metformin . . . . . . 23ERY-TAB . . . . . . . . . . . . . . . . . . 29ERYC . . . . . . . . . . . . . . . . . . . . 29ERYGEL . . . . . . . . . . . . . . . . . . 16ERYTHROCIN . . . . . . . . . . . . . 29erythromycin . . . . . . . 16, 29, 38erythromycin delayed-release 29erythromycin ethylsuccinate . 29erythromycin stearate . . . . . . . 29erythromycin/sulfisoxazole . . 29ESBRIET . . . . . . . . . . . . . . . . . 48ESGIC . . . . . . . . . . . . . . . . . . . . 13esomeprazole . . . . . . . . . . . . . 26esomeprazole granules . . . . . 26ESTRACE . . . . . . . . . . . . . . . . . 35ESTRACE CRM. . . . . . . . . . . . 35estradiol . . . . . . . . . . . . . . . . . . 35estramustine phosphate

sodium . . . . . . . . . . . . . . . . . 4

estrogens, conjugated . . . . . . 35estrogens, conjugated/

medroxyprogesterone . . . 35estropipate . . . . . . . . . . . . . . . . 35ESTROSTEP FE . . . . . . . . . . . 35etanercept . . . . . . . . . . . . . . . . 32ethambutol . . . . . . . . . . . . . . . . 28ethionamide . . . . . . . . . . . . . . . 29ethynodiol diacetate/EE . . . . . 34etidronate . . . . . . . . . . . . . . . . . 24etodolac . . . . . . . . . . . . . . .13, 33etonogestrel/EE . . . . . . . . . . . 34etoposide . . . . . . . . . . . . . . . . . . 6EUCRISA . . . . . . . . . . . . . . . . . 19EULEXIN . . . . . . . . . . . . . . . . . . 5EURAX . . . . . . . . . . . . . . . . . . . 18everolimus . . . . . . . . . . . . . . . 4, 6EVISTA . . . . . . . . . . . . . . . . . . . 24EXCEDRIN MIGRAINE . . . . . . 13EXELON . . . . . . . . . . . . . . . . . . 12exemestane . . . . . . . . . . . . . . . . 5EXJADE . . . . . . . . . . . . . . . . . . . 7ezetimibe . . . . . . . . . . . . . . . . . 11

Ffamotidine . . . . . . . . . . . . .26, 53FANTASY . . . . . . . . . . . . . . . . . 52FARESTON . . . . . . . . . . . . . . . . 5FARYDAK . . . . . . . . . . . . . . . . . . 4febuxostat . . . . . . . . . . . . . . . . 33FELDENE . . . . . . . . . . . . . .13, 33felodipine extended-release . . 9FEMARA . . . . . . . . . . . . . . . . . . 5fenofibrate . . . . . . . . . . . . . . . . 11fentanyl transdermal . . . . . . . . 14FEOSOL . . . . . . . . . . . . . . .45, 54FERGON . . . . . . . . . . . . . . . . . 54ferrous bis-glycinate chelate . 54ferrous fumarate . . . . . . . . . . . 54ferrous gluconate . . . . . . . . . . 54ferrous sulfate . . . . . . . . . .45, 54fidaxomicin . . . . . . . . . . . . . . . 29filgrastim . . . . . . . . . . . . . . . . . . . 7FINACEA . . . . . . . . . . . . . . . . . 16finasteride . . . . . . . . . . . . . . . . 44fingolimod . . . . . . . . . . . . . . . . 15

FIORICET . . . . . . . . . . . . . .13, 14FIORICET W/CODEINE . . . . . 14FIORINAL . . . . . . . . . . . . . .13, 14FIORINAL W/CODEINE . . . . . 14FIRAZYR . . . . . . . . . . . . . . . . . 48FLAGYL . . . . . . . . . . . . . . .31, 36flecainide . . . . . . . . . . . . . . . . . . 9FLEET ENEMA . . . . . . . . . . . . 53FLEET PHOSPHO-SODA . . . 53FLEXERIL . . . . . . . . . . . . . . . . . 33FLOMAX. . . . . . . . . . . . . . . . . . 44FLONASE . . . . . . . . . . . . . . . . . 21FLORAJEN . . . . . . . . . . . .28, 53FLORANEX . . . . . . . . . . . .28, 53FLORASTOR . . . . . . . . . . .28, 53FLORINEF . . . . . . . . . . . . . . . . 22FLOXIN . . . . . . . . . . . . . . . .20, 29FLOXIN OTIC . . . . . . . . . . . . . . 20FLUARIX QUAD . . . . . . . . . . . 49FLUBLOK . . . . . . . . . . . . . . . . . 49FLUCELVAX . . . . . . . . . . . . . . . 49fluconazole . . . . . . . . . . . .30, 36fludrocortisone . . . . . . . . . . . . 22FLULAVAL QUAD . . . . . . . . . . 49FLUMADINE . . . . . . . . . . . . . . 31fluocinolone acetonide . . . . . . 17fluocinonide . . . . . . . . . . . . . . . 17fluocinonide emulsified base 17fluoride . . . . . . . . . . . . 46, 47, 54fluoride dental rinse . . . . . . . . 54fluorometholone . . . . . . . . . . . 37fluorouracil . . . . . . . . . . . . . . . . 19flurbiprofen . . . . . . . . . . . . . . . 36flutamide . . . . . . . . . . . . . . . . . . 5fluticasone . . . . . . . . . 17, 21, 43fluticasone furoate . . . . . . . . . 43fluticasone propionate . . . . . . 17fluticasone/salmeterol . . . . . . 43fluticasone/vilanterol . . . . . . . 43FLUVIRIN . . . . . . . . . . . . . . . . . 49FLUZONE HD PF . . . . . . . . . . 49FLUZONE QUAD. . . . . . . . . . . 49FLUZONE SPLT . . . . . . . . . . . 49FML . . . . . . . . . . . . . . . . . . . . . . 37FML FORTE . . . . . . . . . . . . . . . 37FML LIQUIFILM . . . . . . . . . . . . 37

61



folic acid . . . . . . . . . . . . . . .46, 47FOLTABS PAK PLUS DHA RE

OB + DHA PAK . . . . . . . . . 46FOLTABS PRENATAL . . . . . . . 47FORTICAL . . . . . . . . . . . . . . . . 24FOSAMAX . . . . . . . . . . . . . . . . 24fosinopril. . . . . . . . . . . . . . . . . . . 8fosinopril/hydrochlorothiazide 8FURADANTIN SUSP

25 MG/5 ML . . . . . . . . . . . 31furosemide . . . . . . . . . . . . . . . . 10

Ggalantamine . . . . . . . . . . . . . . . 12ganciclovir . . . . . . . . . . . . . . . . 30GARDASIL . . . . . . . . . . . . . . . . 49GARDASIL 9 . . . . . . . . . . . . . . 49GATTEX . . . . . . . . . . . . . . . . . . 28gefitinib . . . . . . . . . . . . . . . . . . . . 4GEL-KAM . . . . . . . . . . . . . . . . . 46gemfibrozil . . . . . . . . . . . . . . . . 11GENGRAF . . . . . . . . . . . . . . . . . 6GENTAK . . . . . . . . . . . . . . .16, 38gentamicin . . . . . . . . . 16, 37, 38gentamicin/prednisolone

acetate . . . . . . . . . . . . . . . . 37GENTEX ADE 28-1 MG . . . . . 46GG/CODEINE . . . . . . . . . . . . . 40GG/DM CR . . . . . . . . . . . . . . . 41GILENYA . . . . . . . . . . . . . . . . . 15GILOTRIF . . . . . . . . . . . . . . . . . . 4glatiramer acetate . . . . . . . . . . 15GLATOPA . . . . . . . . . . . . . . . . . 15glecaprevir/pibrentasvir . . . . . 31GLEEVEC . . . . . . . . . . . . . . . . . 5GLEOSTINE . . . . . . . . . . . . . . . . 4glimepiride . . . . . . . . . . . . . . . . 23glipizide . . . . . . . . . . . . . . . . . . 23glipizide extended-release . . . 23GLUCAGON . . . . . . . . . . . . . . 22glucagon, human

recombinant . . . . . . . . . . . 22GLUCOPHAGE . . . . . . . . . . . . 24GLUCOPHAGE ER . . . . . . . . . 24glucose oral tablets . . . . . . . . 52GLUCOTROL . . . . . . . . . . . . . 23

GLUCOTROL XL . . . . . . . . . . . 23GLUCOVANCE . . . . . . . . . . . . 24glyburide . . . . . . . . . . . . . .23, 24glyburide, micronized . . . . . . . 24glycerin . . . . . . . . . . . . 25, 36, 51GLYCERIN SUPPOSITORY . . 25GLYCERIN TOPICAL . . . . . . . 51glycerol phenylbutyrate . . . . . 49glycopyrrolate . . . . . . . . . . . . . 27GLYNASE . . . . . . . . . . . . . . . . . 24GRIFULVIN V . . . . . . . . . . . . . . 30GRIS-PEG . . . . . . . . . . . . . . . . 30griseofulvin microsize . . . . . . . 30griseofulvin ultramicrosize . . . 30guaifenesin . . . . . . . . . . . . 40-43guaifenesin extended-release 41guaifenesin/

pseudoephedrine . . . .40, 41guaifenesin/pseudoephedrine

extended-release . . . . . . . 41guaifenesin/pseudoephedrine/

dextromethorphan . . . . . . 41guanabenz . . . . . . . . . . . . . . . . 12guanfacine . . . . . . . . . . . . . . 8, 39guanfacine ER . . . . . . . . . . . . . 39GUIATUSS AC . . . . . . . . . . . . . 40GUIATUSS DAC . . . . . . . . . . . 40GYNE-LOTRIMIN . . . . . . .36, 51GYNOL II . . . . . . . . . . . . . . . . . 52

HHAEGARDA . . . . . . . . . . . . . . . 48halobetasol . . . . . . . . . . . . . . . 17HAVRIX . . . . . . . . . . . . . . . . . . . 49HECORIA . . . . . . . . . . . . . . . . . . 6HEMLIBRA . . . . . . . . . . . . . . . . 7heparin . . . . . . . . . . . . . . . . . . . . 7hepatitis a vaccine susp . . . . . 49hepatitis b vaccine

(recombinant) . . . . . . . . . . 49hepatitis b vaccine recombinant

adjuvanted . . . . . . . . . . . . . 49HEPLISAV-B . . . . . . . . . . . . . . 49HEXALEN . . . . . . . . . . . . . . . . . 4HIPREX . . . . . . . . . . . . . . . . . . 45homatropine . . . . . . . . . . .38, 41

HUMALOG MIX 50/50. . . . . . 23HUMALOG MIX 75/25. . . . . . 23human papillomavirus (hpv)

9-valent recomb vac . . . . . 49human papillomavirus (hpv)

quadrivalent recombinant vac . . . . . . . . . . . . . . . . . . . 49

HUMATIN . . . . . . . . . . . . . . . . . 31HUMIRA . . . . . . . . . . . . . . . . . . 32HUMULIN. . . . . . . . . . . . . .23, 52HUMULIN 70/30 . . . . . . . . . . 23HUMULIN N . . . . . . . . . . . . . . . 23HUMULIN R . . . . . . . . . . . . . . . 23HYCAMTIN . . . . . . . . . . . . . . . . 7HYCODAN . . . . . . . . . . . . . . . . 41hydralazine. . . . . . . . . . . . . . . . 12HYDREA . . . . . . . . . . . . . . . . . . 6hydrochlorothiazide . . . . . . 8-10hydrocodone ER . . . . . . . . . . . 14hydrocodone/

acetaminophen . . . . . . . . . 14hydrocodone/homatropine . . 41HYDROCODONE/TAB

HOMATROP . . . . . . . . . . . 41hydrocortisone

. .17, 19, 20, 22, 27, 37, 52hydrocortisone butyrate . . . . . 17hydrocortisone crm, oint . . . . 52hydrocortisone valerate . . . . . 17hydrocortisone/aloe . . . . . . . . 17HYDROMET SYP . . . . . . . . . . 41hydromorphone . . . . . . . . . . . 14hydroxychloroquine . . . . .31, 32hydroxyurea . . . . . . . . . . . . . . . . 6hyoscyamine . . . . . . . . . . .27, 44hyoscyamine sulfate . . . . . . . . 27hyoscyamine sulfate extended-

release . . . . . . . . . . . . . . . . 27HYPERCARE 15% . . . . . . . . . 19HYPERSAL . . . . . . . . . . . . . . . 48HYPERTET S/D . . . . . . . . . . . 50HYPOTEARS . . . . . . . . . . . . . . 53HYTONE . . . . . . . . . . . . . . . . . 17HYTRIN . . . . . . . . . . . . . . . . 8, 44HYZAAR . . . . . . . . . . . . . . . . . . 9

62


Index of Covered DrugsI

IBRANCE . . . . . . . . . . . . . . . . . . 5ibrutinib . . . . . . . . . . . . . . . . . . . 4IBUOROFEN TAB COLD/

SIN . . . . . . . . . . . . . . . . . . . 43ibuprofen . . . . . . . . . . 13, 33, 54ibuprofen tabs, chew tabs, susp,

drops . . . . . . . . . . . . . . . . . 54icatibant . . . . . . . . . . . . . . . . . . 48ICLUSIG . . . . . . . . . . . . . . . . . . . 5idelalisib . . . . . . . . . . . . . . . . . . . 4ILARIS . . . . . . . . . . . . . . . . . . . 32imatinib mesylate . . . . . . . . . . . 5IMBRUVICA . . . . . . . . . . . . . . . . 4IMDUR . . . . . . . . . . . . . . . . . . . 11imiquimod 5% cream . . . . . . . 19IMITREX . . . . . . . . . . . . . . . . . . 15IMITREX 4 MG AND

6 MG INJ . . . . . . . . . . . . . . 15IMODIUM A-D . . . . . . . . . .25, 53IMPAVIDO . . . . . . . . . . . . . . . . 30IMURAN . . . . . . . . . . . . . . . . 6, 32INCRELEX . . . . . . . . . . . . . . . . 24INCRUSE ELLIPTA . . . . . . . . . 43indacaterol . . . . . . . . . . . . . . . . 43indapamide . . . . . . . . . . . . . . . 10INDERAL . . . . . . . . . . . . . . . 9, 15INDERAL LA . . . . . . . . . . . . . . . 9INDERIDE . . . . . . . . . . . . . . . . . 9INDOCIN . . . . . . . . . . . . . .13, 33indomethacin . . . . . . . . . .13, 33INFLAMASE FORTE . . . . . . . . 37influenza virus vaccine

recombinant hemagglutinin (ha) . . . . . . . . . . . . . . . . . . . 49

influenza virus vaccine split . . 49influenza virus vaccine split

high-dose pf . . . . . . . . . . . 49influenza virus vaccine split pf 49influenza virus vaccine split

quadrivalent . . . . . . . . . . . . 49influenza virus vaccine tiss-cult

subunit . . . . . . . . . . . . . . . . 49influenza virus vaccine types

a&b surface antigen . . . . . 49INGREZZA . . . . . . . . . . . . . . . . 16

INLYTA . . . . . . . . . . . . . . . . . . . . 4insulin (vials only) . . . . . . . . . . 52insulin aspart protamine 70%/

insulin aspart 30% . . . . . . 22insulin glargine . . . . . . . . . . . . 22insulin glargine 300 units/ml 22insulin glargine/lixisenatide . . 22insulin human . . . . . . . . . . . . . 23insulin isophane . . . . . . . . . . . 23insulin isophane human . . . . . 23insulin isophane human 70%/

regular 30% . . . . . . . . . . . . 23insulin isophane/regular . . . . 23insulin lisopro pro/lispro . . . . 23insulin lisopro prot/lispro . . . . 23insulin lispro . . . . . . . . . . . . . . . 23insulin regular . . . . . . . . . . . . . 23insulin syringes . . . . . . . . . . . . 48INTAL . . . . . . . . . . . . . . . . . . . . 44interferon alfa-2b . . . . . . . . . 6, 31interferon gamma-1b . . . . . . . . 6INTRON A . . . . . . . . . . . . . . 6, 31INTUNIV . . . . . . . . . . . . . . . . . . 39ipratropium . . . . . . . . 21, 43, 44ipratropium HFA . . . . . . . . . . . 43ipratropium nasal . . . . . . . . . . 21ipratropium/albuterol . . . .43, 44IRESSA . . . . . . . . . . . . . . . . . . . . 4iron . . . . . . . . 34, 35, 46, 47, 54ISMO . . . . . . . . . . . . . . . . . . . . . 11isoniazid . . . . . . . . . . . . . . . . . . 29ISOPTO ATROPINE . . . . . . . . 38ISOPTO CARPINE . . . . . . . . . 38ISOPTO HOMATROPINE. . . . 38ISOPTO HYOSCINE . . . . . . . . 38ISORDIL . . . . . . . . . . . . . . . . . . 11ISORDIL S.L. . . . . . . . . . . . . . . 11isosorbide dinitrate . . . . . . . . . 11ISOSORBIDE DINITRATE ER 11isosorbide dinitrate extended-

release . . . . . . . . . . . . . . . . 11isosorbide mononitrate . . . . . 11isosorbide mononitrate

extended-release . . . . . . . 11isotretinoin . . . . . . . . . . . . . . . . 16itraconazole . . . . . . . . . . . . . . . 30

ivacaftor . . . . . . . . . . . . . . . . . . 48ivermectin . . . . . . . . . . . . . . . . 28ixazomib . . . . . . . . . . . . . . . . . . . 5

JJADENU . . . . . . . . . . . . . . . . . . . 7JAKAFI . . . . . . . . . . . . . . . . . . . . 5

KK-DUR 10 . . . . . . . . . . . . . . . . . 47K-DUR 20 . . . . . . . . . . . . . . . . . 47K-LOR . . . . . . . . . . . . . . . . . . . . 47K-LYTE . . . . . . . . . . . . . . . . . . . 47K-PHOS NEUTRAL . . . . . . . . . 47K-PHOS ORIGINAL . . . . . . . . 47KALYDECO . . . . . . . . . . . . . . . 48KALYDECO GRANULES . . . . 48KAOPECTATE . . . . . . . . . . . . . 53KAYEXALATE . . . . . . . . . . . . . 12KAZANO . . . . . . . . . . . . . . . . . 23KEFLEX . . . . . . . . . . . . . . . . . . 29KENALOG . . . . . . . . . . . . .17, 21KENALOG IN ORABASE . . . . 21KERLONE . . . . . . . . . . . . . . . . . 9ketoconazole . . . . . . . 18, 19, 30ketoprofen . . . . . . . . . . . . .13, 33ketorolac . . . . . . . . . . . . . .13, 36ketorolac tromethamine . . . . . 13ketotifen . . . . . . . . . . . . . . . . . . 36KEVZARA . . . . . . . . . . . . . . . . 32KIMONO. . . . . . . . . . . . . . . . . . 52KINERET . . . . . . . . . . . . . . . . . 32KLOR-CON 10 . . . . . . . . . . . . 47KLOR-CON 8 . . . . . . . . . . . . . 47KORLYM . . . . . . . . . . . . . . . . . 25KUVAN . . . . . . . . . . . . . . . . . . . 25KUVAN POWDER FOR

SOLUTION . . . . . . . . . . . . 25

Llabetalol . . . . . . . . . . . . . . . . . . . 9LAC-HYDRIN . . . . . . . . . . . . . . 19LACTINEX . . . . . . . . . . . . .28, 53LACTINOL . . . . . . . . . . . . . . . . 19lactulose . . . . . . . . . . . . . . . . . . 25LAMISIL . . . . . . . . . . . . . . .18, 30

63



LAMISIL AT . . . . . . . . . . . . . . . 18lamivudine . . . . . . . . . . . . . . . . 31lancets . . . . . . . . . . . . . . . . . . . 48LANOXIN . . . . . . . . . . . . . . . . . . 9lansoprazole . . . . . . . . . . . . . . 26lansoprazole delayed-release 26lapatinib ditosylate . . . . . . . . . . 5LARIAM . . . . . . . . . . . . . . . . . . 31LASIX . . . . . . . . . . . . . . . . . . . . 10latanoprost . . . . . . . . . . . . . . . . 38laxative enemas . . . . . . . . . . . 53laxatives . . . . . . . . . . . . 2, 25, 53leflunomide . . . . . . . . . . . . . . . 32lenalidomide . . . . . . . . . . . . . . . 6lenvatinib . . . . . . . . . . . . . . . . . . 5LENVIMA . . . . . . . . . . . . . . . . . . 5LETAIRIS . . . . . . . . . . . . . . . . . 12letrozole . . . . . . . . . . . . . . . . . . . 5leucovorin . . . . . . . . . . . . . . . . . 5LEUKERAN . . . . . . . . . . . . . . . . 4LEUKINE . . . . . . . . . . . . . . . . . . 7leuprolide . . . . . . . . . . . . . . . . . . 5levalbuterol HCl . . . . . . . . . . . . 44LEVAQUIN . . . . . . . . . . . . . . . . 29levobunolol . . . . . . . . . . . . . . . 37levocetirizine . . . . . . . . . . . . . . 20levofloxacin . . . . . . . . . . . . . . . 29levonorgestrel . . . . . . . . . .34, 35levonorgestrel/EE . . . . . . .34, 35levothyroxine . . . . . . . . . . . . . . 24LEVOXYL . . . . . . . . . . . . . . . . . 24LEVSIN . . . . . . . . . . . . . . . . . . . 27LEVSINEX . . . . . . . . . . . . . . . . 27LIDAMANTEL . . . . . . . . . . . . . 19LIDEX . . . . . . . . . . . . . . . . . . . . 17LIDEX E . . . . . . . . . . . . . . . . . . 17lidocaine . . . . . . . . . . . . . . .19, 21lidocaine patch . . . . . . . . . . . . 19lidocaine viscous . . . . . . . . . . 21lidocaine/prilocaine . . . . . . . . 19LIDODERM . . . . . . . . . . . . . . . 19LIFESTYLES . . . . . . . . . . . . . . 52lifitegrast . . . . . . . . . . . . . . . . . . 38linaclotide . . . . . . . . . . . . . . . . . 25linezolid . . . . . . . . . . . . . . . . . . 31LINZESS . . . . . . . . . . . . . . . . . . 25

liothyronine . . . . . . . . . . . . . . . 24liotrix . . . . . . . . . . . . . . . . . . . . . 24LIPITOR . . . . . . . . . . . . . . . . . . 11lisinopril . . . . . . . . . . . . . . . . 8, 72lisinopril/hydrochlorothiazide . 8lixisenatide . . . . . . . . . . . . .22, 24LMX-4 . . . . . . . . . . . . . . . . . . . . 19LO/OVRAL . . . . . . . . . . . . . . . . 34LOCOID . . . . . . . . . . . . . . . . . . 17LODINE . . . . . . . . . . . . . . .13, 33LOESTRIN 1/20 . . . . . . . . . . . 34LOESTRIN 1.5/30 . . . . . . . . . 34LOESTRIN FE 1/20 . . . . . . . . 34LOESTRIN FE 1.5/30 . . . . . . . 34LOFIBRA . . . . . . . . . . . . . . . . . 11LOHIST-D . . . . . . . . . . . . . . . . . 40LOMOTIL . . . . . . . . . . . . . . . . . 25lomustine . . . . . . . . . . . . . . . . . . 4LONITEN . . . . . . . . . . . . . . . . . 12LONSURF . . . . . . . . . . . . . . . . . 4loperamide . . . . . . . . . . . . . . . . 25LOPID . . . . . . . . . . . . . . . . . . . . 11LOPRESSOR . . . . . . . . . . . . . . . 9loratadine . . . . . . . 20, 21, 41, 51loratadine & pseudoephedrine

SR 24hr . . . . . . . . . . . . . . . 41loratadine/

pseudoephedrine 21, 41, 51loratadine/pseudoephedrine

extended-release . . . . . . . 21LORCET . . . . . . . . . . . . . . . . . . 14LORTAB . . . . . . . . . . . . . . . . . . 14LORTAB ELIXIR . . . . . . . . . . . 14losartan . . . . . . . . . . . . . . . . . 8, 9losartan/HCTZ . . . . . . . . . . . . . 9LOTENSIN . . . . . . . . . . . . . . . . . 8LOTENSIN HCT . . . . . . . . . . . . 8LOTRIMIN AF . . . . . . . . . .18, 51LOTRISONE . . . . . . . . . . . . . . . 18lovastatin . . . . . . . . . . . . . . . . . 11LOVAZA . . . . . . . . . . . . . . . . . . 11LOVENOX . . . . . . . . . . . . . . . . . 7LOZOL . . . . . . . . . . . . . . . . . . . 10lumacaftor/ivacaftor . . . . . . . . 48LUPRON . . . . . . . . . . . . . . . . . . 5LUPRON DEPOT . . . . . . . . . . . 5

LUPRON DEPOT 6-MONTH . . 5LUPRON DEPOT-PED . . . . . . . 5LURIDE . . . . . . . . . . . . . . . . . . . 46LURIDE LOZI-TABS. . . . . . . . . 46LYNPARZA . . . . . . . . . . . . . . . . 6LYSODREN . . . . . . . . . . . . . . . . 6LYSTEDA . . . . . . . . . . . . . . . . . 36

MM-CLEAR WC . . . . . . . . . . . . . 40M-M-R II . . . . . . . . . . . . . . . . . . 50MAALOX . . . . . . . . . . . . . .26, 52MAALOX LIQUID . . . . . . . . . . 52macitentan . . . . . . . . . . . . . . . . 12MACROBID . . . . . . . . . . . . . . . 31MACRODANTIN . . . . . . . . . . . 31MAG-OX . . . . . . . . . . . . . . .46, 54magnesium citrate soln . . . . . 25magnesium oxide . . . . . . .46, 54malathion . . . . . . . . . . . . . . . . . 18MAPAP COLD TAB . . . . . . . . 42MARINOL . . . . . . . . . . . . . . . . . 25MATERNA . . . . . . . . . . . . . . . . 47MATULANE . . . . . . . . . . . . . . . . 7MAVIK . . . . . . . . . . . . . . . . . . . . . 8MAVYRET . . . . . . . . . . . . . . . . 31MAXALT/MAXALT MLT . . . . . 15MAXITROL. . . . . . . . . . . . . . . . 37MAXZIDE . . . . . . . . . . . . . . . . . 10measles, mumps & rubella

virus vaccines for inj . . . . . 50mecasermin . . . . . . . . . . . . . . . 24meclizine . . . . . . . . . . . . . .25, 53MEDROL . . . . . . . . . . . . . . . . . 22medroxyprogesterone

acetate . . . . . . . . . . . . .34, 35mefloquine . . . . . . . . . . . . . . . . 31MEGACE . . . . . . . . . . . . . . . . . . 6megestrol acetate . . . . . . . . . . . 6MEKINIST . . . . . . . . . . . . . . . . . 5meloxicam . . . . . . . . . . . . .13, 33melphalan . . . . . . . . . . . . . . . . . 4memantine . . . . . . . . . . . . . . . . 12MENACTRA . . . . . . . . . . . . . . . 50meningococcal (a, c, y, and

w-135) . . . . . . . . . . . . . . . . 50

64


Index of Covered Drugsmeningococcal (a, c, y, and

w-135) conjugate vaccine . . . . . . . . . . . . . . . . 50

meningococcal (a, c, y, and w-135) oligo conj vac for inj . . . . . . . . . . . . . . . . . . 50

MENOMUNE . . . . . . . . . . . . . . 50MENVEO . . . . . . . . . . . . . . . . . 50meperidine . . . . . . . . . . . . . . . . 14MEPHYTON . . . . . . . . . . . . . . 46MEPRON . . . . . . . . . . . . . . . . . 30mercaptopurine . . . . . . . . . . . . . 4mesalamine . . . . . . . . . . . . . . . 27mesalamine

extended-release . . . . . . . 27mesalamine supp . . . . . . . . . . 27mesna . . . . . . . . . . . . . . . . . . . . . 5MESNEX . . . . . . . . . . . . . . . . . . 5MESTINON . . . . . . . . . . . . . . . 15MESTINON TIMESPAN . . . . . 15METAMUCIL . . . . . . . . . . . . . . 53metaproterenol . . . . . . . . . . . . 44METAPROTERENOL SYRUP 44metformin . . . . . . . . . . . . . .23, 24metformin ER . . . . . . . . . . . . . 24metformin/glyburide . . . . . . . . 24methazolamide . . . . . . . . . . . . 38methenamine . . . . . . . . . .44, 45methenamine hippurate . . . . . 45METHERGINE . . . . . . . . . .24, 36methimazole . . . . . . . . . . . . . . 24methocarbamol . . . . . . . . . . . . 33methotrexate . . . . . . . . . . . . . . 32methoxsalen . . . . . . . . . . . . . . 18methyldopa . . . . . . . . . . . . . . . 12methyldopa/HCTZ . . . . . . . . . 12methylene blue . . . . . . . . . . . . 44methylergonovine . . . . . . .24, 36methylprednisolone . . . . . . . . 22metipranolol . . . . . . . . . . . . . . . 37metoclopramide . . . . . . . . . . . 25metolazone . . . . . . . . . . . . . . . 10metoprolol . . . . . . . . . . . . . . . . . 9metoprolol succinate . . . . . . . . 9METROCREAM . . . . . . . . . . . 18METROGEL . . . . . . . . . . . .18, 36

METROGEL 1% . . . . . . . . . . . 36METROGEL-VAGINAL . . . . . . 36METROLOTION . . . . . . . . . . . 18metronidazole . . . . . . 18, 31, 36MEVACOR . . . . . . . . . . . . . . . . 11mexiletine . . . . . . . . . . . . . . . . . . 9MEXITIL . . . . . . . . . . . . . . . . . . . 9MIACALCIN . . . . . . . . . . . . . . . 24MICATIN . . . . . . . . . . . . . . .18, 51miconazole . . . . . . . . 18, 36, 51miconazole crm . . . . . . . . . . . 51MICRO-K 10 . . . . . . . . . . . . . . 47MICRONASE . . . . . . . . . . . . . . 23MICROZIDE . . . . . . . . . . . . . . . 10MIDAMOR . . . . . . . . . . . . . . . . 10midodrine . . . . . . . . . . . . . . . . . 12midostaurin . . . . . . . . . . . . . . . . 5mifepristone . . . . . . . . . . . . . . . 25MIGERGOT

SUPPOSITORIES . . . . . . . 14milnacipran . . . . . . . . . . . . . . . 33miltefosine . . . . . . . . . . . . . . . . 30MINIPRESS . . . . . . . . . . . . . . . . 8MINOCIN . . . . . . . . . . . . . . . . . 30minocycline . . . . . . . . . . . . . . . 30minoxidil . . . . . . . . . . . . . . . . . . 12MINUTUSS DR SYP . . . . . . . . 42MIRALAX . . . . . . . . . . . . . . . . . 25MIRAPEX . . . . . . . . . . . . . . . . . 15MIRCETTE . . . . . . . . . . . . . . . . 34MIRVASO . . . . . . . . . . . . . . . . . 18misoprostol . . . . . . . . . . . . . . . 28MITIGARE . . . . . . . . . . . . . . . . 33mitotane . . . . . . . . . . . . . . . . . . . 6MOBIC . . . . . . . . . . . . . . . .13, 33MODICON . . . . . . . . . . . . . . . . 34MODURETIC . . . . . . . . . . . . . . 10mometasone . . . . . . . . . . .17, 43mometasone furoate . . . . . . . 17MONISTAT . . . . . . . . . . . . .36, 51MONISTAT 3 . . . . . . . . . . . . . . 36MONISTAT-DERM . . . . . . . . . . 18MONOPRIL . . . . . . . . . . . . . . . . 8MONOPRIL-HCT . . . . . . . . . . . . 8montelukast . . . . . . . . . . . . . . . 44morphine . . . . . . . . . . . . . . . . . 14

morphine extended-release . . 14MOTRIN . . . . . . . . . . . 13, 33, 54MOTRIN IB . . . . . . . . . . . . . . . 54MOVANTIK . . . . . . . . . . . . . . . 28MOZOBIL . . . . . . . . . . . . . . . . . . 7MS CONTIN . . . . . . . . . . . . . . . 14MSIR . . . . . . . . . . . . . . . . . . . . . 14MUCINEX . . . . . . . . . . . . . . . . . 41MUCINEX D . . . . . . . . . . . . . . . 41MUCINEX DM . . . . . . . . . . . . . 41MUCOMYST . . . . . . . . . . . . . . 48MULTI SYMPTOM TAB COLD

RLF . . . . . . . . . . . . . . . . . . . 43multivitamins/fluoride/±iron . 46multivitamins/minerals . . . . . . 46mupirocin . . . . . . . . . . . . . . . . . 16MURINE . . . . . . . . . . . . . . . . . . 54MURO 128 . . . . . . . . . . . . . . . 39MYAMBUTOL . . . . . . . . . . . . . 28MYCELEX . . . . . . . . . . . . .18, 30MYCOBUTIN . . . . . . . . . . . . . . 29mycophenolate mofetil . . . . . . . 6mycophenolate sodium . . . . . . 6MYCOSTATIN . . . . . . . . . .18, 30MYFORTIC. . . . . . . . . . . . . . . . . 6MYLANTA . . . . . . . . . . . . .26, 52MYLANTA LIQUID . . . . . . . . . 52MYLERAN . . . . . . . . . . . . . . . . . 4MYLICON . . . . . . . . . . . . . . . . . 53MYORISAN . . . . . . . . . . . . . . . 16MYSOLINE . . . . . . . . . . . . . . . . 15MYTESI . . . . . . . . . . . . . . . . . . 25

Nnabumetone . . . . . . . . . . . . . . 13naloxegol . . . . . . . . . . . . . . . . . 28naloxone . . . . . . . . . . . . . . .14, 39NAMENDA . . . . . . . . . . . . . . . . 12naphazoline HCL . . . . . . . . . . 36naphazoline/glycerin . . . . . . . 36naphazoline/zinc sulfate . . . . 36NAPHCON A . . . . . . . . . . . . . . 54NAPROSYN . . . . . . . . . . . .13, 33naproxen . . . . . . . . . . . . . .13, 33naproxen delayed release 13, 33naratriptan . . . . . . . . . . . . . . . . 15

65



NARCAN NASAL SPRAY . . . 39NASACORT ALLERGY 24

HOUR . . . . . . . . . . . . . . . . . 21nasal sprays . . . . . . . . . . . . . . . 52NASALCROM . . . . . . . . . . . . . 21nateglinide . . . . . . . . . . . . . . . . 24NATROBA . . . . . . . . . . . . . . . . 18NEBUPENT . . . . . . . . . . . . . . . 30NEBUSAL . . . . . . . . . . . . . . . . 48NEO-SYNEPHRINE . . . . .21, 52neomycin sulfate . . . . . . . . . . . 31neomycin/bacitracin/

polymyxin . . . . . . . . . . . . . . 38neomycin/polymyxin B/

bacitracin . . . . . . . . . . . . . . 16neomycin/polymyxin B/

dexamethasone . . . . . . . . 37neomycin/polymyxin B/

gramicidin . . . . . . . . . . . . . 38neomycin/polymyxin B/

hydrocortisone . . . . . .20, 37NEORAL . . . . . . . . . . . . . . . . . . 6NEOSPORIN . . . . . . . 16, 38, 52NEPHROCAPS . . . . . . . . . . . . 47NEPTAZANE . . . . . . . . . . . . . . 38NESINA . . . . . . . . . . . . . . . . . . 23NESTABS . . . . . . . . . . . . . . . . . 47NEULASTA . . . . . . . . . . . . . . . . 7NEUMEGA . . . . . . . . . . . . . . . . . 7NEUTROGENA OIL FREE

ACNE WASH . . . . . . . . . . . 16NEXAVAR . . . . . . . . . . . . . . . . . 5NEXIUM 24HR OTC . . . . . . . . 26NEXIUM DELAYED RELEASE

PACKET . . . . . . . . . . . . . . . 26niacin . . . . . . . . . . . . . . . . . . . . 11niacin extended-release . . . . . 11NIACOR . . . . . . . . . . . . . . . . . . 11NIASPAN . . . . . . . . . . . . . . . . . 11nicardipine . . . . . . . . . . . . . . . . . 9nifedipine . . . . . . . . . . . . . . . . . 10nifedipine extended-release . 10nilotinib . . . . . . . . . . . . . . . . . . . . 5nimodipine . . . . . . . . . . . . . . . . 10nimodipine oral soln . . . . . . . . 10NIMOTOP. . . . . . . . . . . . . . . . . 10

NINLARO . . . . . . . . . . . . . . . . . . 5nintedanib . . . . . . . . . . . . . . . . 48niraparib . . . . . . . . . . . . . . . . . . . 6nitazoxanide suspension . . . . 30nitazoxanide tablet . . . . . . . . . 30nitisinone . . . . . . . . . . . . . . . . . 25NITREK . . . . . . . . . . . . . . . . . . 11NITRO-BID . . . . . . . . . . . . . . . . 11NITRO-DUR . . . . . . . . . . . . . . . 11nitrofurantoin

extended-release . . . . . . . 31nitrofurantoin macrocrystals . 31nitrofurantoin susp . . . . . . . . . 31nitroglycerin . . . . . . . . . . . .11, 19NITROLINGUAL . . . . . . . . . . . 11NITROSTAT . . . . . . . . . . . . . . . 11NITYR . . . . . . . . . . . . . . . . . . . . 25NIX 18, 53NIX CREME RINSE . . . . . . . . . 18NIZORAL . . . . . . . . . . 18, 19, 30NIZORAL SHAMPOO. . . . . . . 19NOLVADEX . . . . . . . . . . . . . . . . 5NORCO . . . . . . . . . . . . . . . . . . 14NORDETTE . . . . . . . . . . . . . . . 34norelgestromin/EE . . . . . . . . . 35norethindrone . . . . . . . . . .34, 35norethindrone acetate . . .34, 35norethindrone acetate/

EE . . . . . . . . . . . . . . . . .34, 35norethindrone acetate/EE/

iron . . . . . . . . . . . . . . . .34, 35norethindrone/EE . . . . . . .34, 35norethindrone/ME . . . . . . . . . 35NORFLEX . . . . . . . . . . . . . . . . 33norgestimate/EE . . . . . . . .34, 35norgestrel/EE . . . . . . . . . .34, 35NORPACE . . . . . . . . . . . . . . . . . 9NORPACE CR . . . . . . . . . . . . . . 9NORVASC . . . . . . . . . . . . . . . . . 9NOVAREL . . . . . . . . . . . . . . . . 36NOVOLIN . . . . . . . . . . . . . .23, 52NOVOLIN 70/30 . . . . . . . . . . . 23NOVOLIN N . . . . . . . . . . . . . . . 23NOVOLIN R . . . . . . . . . . . . . . . 23NOVOLOG MIX 70/30 . . . . . . 22NUEDEXTA . . . . . . . . . . . . . . . 39

NULYTELY . . . . . . . . . . . . . . . . 25NUVARING . . . . . . . . . . . . . . . 34NYMALIZE . . . . . . . . . . . . . . . . 10nystatin . . . . . . . . . . . . . . . .18, 30

OOCEAN NASAL SPRAY . . . . . 21octreotide . . . . . . . . . . . . . . . . . . 6OCUFEN . . . . . . . . . . . . . . . . . 36OCUFLOX . . . . . . . . . . . . . . . . 38ODOMZO . . . . . . . . . . . . . . . . . . 7OFEV . . . . . . . . . . . . . . . . . . . . 48ofloxacin . . . . . . . . . . . 20, 29, 38OGEN . . . . . . . . . . . . . . . . . . . . 35olaparib . . . . . . . . . . . . . . . . . . . 6olodaterol . . . . . . . . . . . . . . . . . 43olsalazine sodium . . . . . . . . . . 27omalizumab . . . . . . . . . . . . . . . 43omega 3 acid ethyl esters . . . 11omeprazole delayed-release . 26OMNICEF . . . . . . . . . . . . . . . . . 29ondansetron . . . . . . . . . . . . . . 26One Touch Systems . . . . . . . . 23One Touch Test Strips . . . . . . 23oprelvekin . . . . . . . . . . . . . . . . . 7OPSUMIT . . . . . . . . . . . . . . . . . 12OPTIPRANOLOL . . . . . . . . . . 37OPTIVAR . . . . . . . . . . . . . . . . . 36ORAPRED . . . . . . . . . . . . . . . . 22ORKAMBI . . . . . . . . . . . . . . . . 48orphenadrine

extended-release . . . . . . . 33ORTHO COIL . . . . . . . . . . . . . 34ortho diaphragm . . . . . . . . . . . 34ORTHO EVRA . . . . . . . . . . . . . 35ORTHO FLAT . . . . . . . . . . . . . 34ORTHO FLEX . . . . . . . . . . . . . 34ORTHO MICRONOR . . . . . . . 35ORTHO TRI-CYCLEN . . . . . . . 35ORTHO-CEPT . . . . . . . . . . . . . 34ORTHO-CYCLEN . . . . . . . . . . 34ORTHO-NOVUM 1/35 . . . . . . 34ORTHO-NOVUM 1/50 . . . . . . 35ORTHO-NOVUM 10/11 . . . . 34ORTHO-NOVUM 7/7/7 . . . . . 35ORUDIS . . . . . . . . . . . . . . .13, 33

66


Index of Covered DrugsOS-CAL . . . . . . . . . . . . . . .45, 54oseltamivir . . . . . . . . . . . . . . . . 31OSENI . . . . . . . . . . . . . . . . . . . . 23OTEZLA . . . . . . . . . . . . . . . . . . 32OVCON 50 . . . . . . . . . . . . . . . . 35OVIDE . . . . . . . . . . . . . . . . . . . . 18OVIDREL . . . . . . . . . . . . . . . . . 36OVRAL . . . . . . . . . . . . . . . .34, 35oxaprozin . . . . . . . . . . . . . .13, 33OXSORALEN-ULTRA . . . . . . . 18oxybutynin chloride . . . . . . . . 45oxybutynin IR . . . . . . . . . . . . . . 45oxybutynin patch. . . . . . . .45, 54oxycodone . . . . . . . . . . . . . . . . 14oxycodone/acetaminophen . 14oxycodone/aspirin . . . . . . . . . 14OXYFAST . . . . . . . . . . . . . . . . . 14oxymetazoline . . . . . . . . . . . . . 21oxymorphone ER . . . . . . . . . . 14OXYTROL FOR WOMEN OTC

PATCH . . . . . . . . . . . . .45, 54

Ppalbociclib . . . . . . . . . . . . . . . . . 5palivizumab . . . . . . . . . . . . . . . 31pancrelipase . . . . . . . . . . . . . . 27panobinostat . . . . . . . . . . . . . . . 4PANRETIN . . . . . . . . . . . . . . . . . 6pantoprazole . . . . . . . . . . . . . . 26PARAFON FORTE DSC . . . . . 33paromomycin . . . . . . . . . . . . . 31PASER . . . . . . . . . . . . . . . . . . . 28pasireotide . . . . . . . . . . . . . . . . . 6patiromer . . . . . . . . . . . . . . . . . 12pazopanib . . . . . . . . . . . . . . . . . 5PEDIACARE LIQ MULTI-SY . . 42PEDIALYTE . . . . . . . . . . . .45, 53PEDIAPRED . . . . . . . . . . . . . . . 22PEDIAZOLE . . . . . . . . . . . . . . . 29peg 3350/electrolytes . . . . . . 25peg 3350/sodium bicarbonate/

sodium chloride . . . . . . . . 25peg 3350/sodium

bicarbonate/sodium chloride/potassium chloride . . . . . . . . . . . . . . . 25

PEGASYS . . . . . . . . . . . . . . . . . 31PEGASYS PROCLICK . . . . . . 31pegfilgrastim . . . . . . . . . . . . . . . 7peginterferon alfa-2a . . . . . . . 31peginterferon alfa-2b . . . . . . . . 6peginterferon beta-1a . . . . . . . 15pegvisomant . . . . . . . . . . . . . . 25penicillamine . . . . . . . . . . . . . . 32penicillin VK . . . . . . . . . . . . . . . 30PENLAC SOLUTION 8% . . . . 18pentamidine isethionate for

nebulization . . . . . . . . . . . . 30pentazocine/naloxone . . . . . . 14pentosan polysulfate sodium 45pentoxifylline

extended-release . . . . . . . . 8PEPCID . . . . . . . . . . . . . . .26, 53PEPCID AC . . . . . . . . . . . .26, 53PERCOCET . . . . . . . . . . . . . . . 14PERCODAN . . . . . . . . . . . . . . . 14PERIDEX . . . . . . . . . . . . . . . . . 21permethrin . . . . . . . . . . . . .18, 53PERSANTINE . . . . . . . . . . . . . . 7phenazopyridine . . . . . . . . . . . 45PHENERGAN . . . . . . . . . .26, 41PHENERGAN DM . . . . . . . . . . 41phenobarbital . . . . . . . . . . . . . 15phenyl salicylate . . . . . . . . . . . 44phenylephrine . . . 21, 39, 40, 42phenylephrine/

brompheniramine/dextromethorphan . . . . . . 42

phenylephrine/chlorpheniramine/ dextromethorphan . . . . . . 42

phenylephrine/chlorpheniramine/dihydrocodeine . . . . . . . . . 42

phenylephrine/dextromethorphan . . . . . . 42

phenylephrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 42

phenylephrine/ephed/CPM w/carbetapentane . . . . . . . . 42

phenylephrine/guaifenesin . . 42

phenylephrine/pyrilamine w/hydrocodone . . . . . . . . . . . 42

PHENYLHIST LIQ DH . . . . . . 40PHENYTEK . . . . . . . . . . . . . . . 15phenytoin . . . . . . . . . . . . . . . . . 15phenytoin sodium extended . 15PHILLIPS COLON

HEALTH . . . . . . . . . . . .28, 53PHOS-FLUR . . . . . . . . . . .46, 54PHOSPHOLINE IODINE . . . . 37phosphorus . . . . . . . . . . . . . . . 47PHRENILIN . . . . . . . . . . . . . . . 13phytonadione. . . . . . . . . . . . . . 46pilocarpine . . . . . . . . . . . . .21, 38PILOPINE HS GEL . . . . . . . . . 38pimecrolimus . . . . . . . . . . . . . . 19PIN-X . . . . . . . . . . . . . . . . . . . . . 28pioglitazone . . . . . . . . . . . .23, 24pirfenidone capsule . . . . . . . . 48piroxicam . . . . . . . . . . . . . .13, 33PLAN B ONE STEP . . . . . . . . 34PLAQUENIL . . . . . . . . . . . .31, 32PLAVIX . . . . . . . . . . . . . . . . . . . . 7PLEGRIDY . . . . . . . . . . . . . . . . 15PLENDIL . . . . . . . . . . . . . . . . . . 9plerixafor . . . . . . . . . . . . . . . . . . 7PLETAL . . . . . . . . . . . . . . . . . . . 7PLEXION . . . . . . . . . . . . . . . . . 16pneumococcal 13-valent

conjugate . . . . . . . . . . . . . . 50pneumococcal vaccine

polyvalent. . . . . . . . . . . . . . 50PNEUMOVAX . . . . . . . . . . . . . 50PNEUMOVAX 23 . . . . . . . . . . 50podofilox . . . . . . . . . . . . . . . . . 18POLY-VI-FLOR . . . . . . . . . . . . . 46POLY-VI-SOL . . . . . . . . . . . . . . 54polyethylene glycol 3350 . . . . 25polymyxin B/bacitracin . .16, 38polymyxin B/trimethoprim . . . 38polysaccharide iron caps . . . . 54POLYSPORIN . . . . . . . . . . . . . 38POLYTRIM . . . . . . . . . . . . . . . . 38pomalidomide . . . . . . . . . . . . . . 6POMALYST . . . . . . . . . . . . . . . . 6ponatinib . . . . . . . . . . . . . . . . . . 5

67



potassium acid phosphate . . 47potassium bicarbonate/

potassium citrate effervescent . . . . . . . . . . . . 47

potassium chloride . . . . . .25, 47potassium chloride extended-

release . . . . . . . . . . . . . . . . 47potassium citrate . . . . . . . .45, 47povidone-iodine . . . . . . . . . . . 32PRALUENT . . . . . . . . . . . . . . . 11pramipexole . . . . . . . . . . . . . . . 15pramlintide . . . . . . . . . . . . . . . . 24PRANDIN . . . . . . . . . . . . . . . . . 24prasugrel . . . . . . . . . . . . . . . . . . 7praziquantel . . . . . . . . . . . . . . . 28prazosin . . . . . . . . . . . . . . . . . . . 8PRECOSE . . . . . . . . . . . . . . . . 23PRED FORTE . . . . . . . . . . . . . 37PRED MILD . . . . . . . . . . . . . . . 37PRED-G . . . . . . . . . . . . . . . . . . 37prednicarbate . . . . . . . . . . . . . 17prednisolone . . . . . . . . . . .22, 37prednisolone acetate . . . . . . . 37prednisolone phosphate . . . . 37prednisolone sodium

phosphate . . . . . . . . . . . . . 22prednisone . . . . . . . . . . . . . . . . 22PRELONE . . . . . . . . . . . . . . . . 22PREMARIN . . . . . . . . . . . . . . . 35PREMPHASE . . . . . . . . . . . . . 35PREMPRO . . . . . . . . . . . . . . . . 35prenat w/o A w/fecbn-fegl-DSS-

FA & DHA . . . . . . . . . . . . . . 46prenat-FE Bis-FE prot succ-FA-

CA & omega 3 . . . . . . . . . 46prenat-FE bis-FE prot succ-FA-

CA & omega DR . . . . . . . . 46prenatal vit w/FE bisglycinate

chelate-FA . . . . . . . . . . . . . 46prenatal vit w/FE polysac

cmplx-FA . . . . . . . . . . . . . . 46prenatal vit w/iron

carbonyl-FA . . . . . . . . . . . . 47prenatal vit w/o vit a w/fe

bisglycinate-fa tab 32-1 mg . . . . . . . . . . . . . . . 47

PRENATAL VITAMINS W/ FOLIC ACID . . . . . . . . 47

prenatal vitamins w/folic acid . . . . . . . . . . . . 47

prenatal w/o A w/ FE carbonyl-FE gluc-DSS-FA 47

PREPARATION H . . . . . . . . . . 53PREVACID . . . . . . . . . . . . . . . . 26PREVACID SOLUTAB . . . . . . 26PREVIDENT . . . . . . . . . . . . . . . 46PREVNAR 13 . . . . . . . . . . . . . 50PRIFTIN . . . . . . . . . . . . . . . . . . 29PRILOSEC . . . . . . . . . . . . . . . . 26primaquine. . . . . . . . . . . . . . . . 32primidone . . . . . . . . . . . . . . . . . 15PRINCIPEN . . . . . . . . . . . . . . . 30PROAMATINE . . . . . . . . . . . . . 12probenecid . . . . . . . . . . . . . . . 33probiotics . . . . . . . . . . . . . .28, 53procarbazine . . . . . . . . . . . . . . . 7PROCARDIA . . . . . . . . . . . . . . 10PROCARDIA XL . . . . . . . . . . . 10prochlorperazine . . . . . . . . . . . 26PROCRIT . . . . . . . . . . . . . . . . . . 7PROCTOSOL HC

CREAM 2.5% . . . . . . . . . . 19PROCTOZONE CREAM-HC

2.5% . . . . . . . . . . . . . . . . . . 19progesterone micronized cap 35PROGRAF . . . . . . . . . . . . . . . . . 6PROMACTA . . . . . . . . . . . . . . . 48PROMETH VC SYP

6.25-5/5 . . . . . . . . . . . . . . . 42promethazine . . . . . . . 26, 40-42promethazine &

phenylephrine . . . . . . .40, 42PROMETHAZINE SYP DM . . 41PROMETHAZINE VC

W/CODEINE . . . . . . . . . . . 40PROMETHAZINE

W/CODEINE . . . . . . . . . . . 40PROMETRIUM . . . . . . . . . . . . 35propafenone . . . . . . . . . . . . . . . 9propantheline . . . . . . . . . . . . . 45propranolol . . . . . . . . . . . . . 9, 15propranolol ER 24HR . . . . . . . 9

propranolol/HCTZ . . . . . . . . . . 9propylthiouracil . . . . . . . . . . . . 24PROSCAR . . . . . . . . . . . . . . . . 44PROTONIX . . . . . . . . . . . . . . . . 26PROTOPIC 0.03% . . . . . . . . . 19PROTOPIC 0.1% . . . . . . . . . . . 19PROVENTIL . . . . . . . . . . . . . . . 44PROVERA . . . . . . . . . . . . . . . . 35PRUET DHA PAK SETONET

PAK . . . . . . . . . . . . . . . . . . . 46PRUET DHAEC PAK . . . . . . . 46PSE/GG . . . . . . . . . . . . . . . . . . 41pseudoephedrine tan/

dexchlorphen tan/DM tan 43pseudoephedrine/

acetaminophen/dextromethorphan . . . . . . 42

pseudoephedrine/chlorpheniramine/dextromethorphan . . . . . . 42

pseudoephedrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 43

pseudoephedrine/iburprofen 43psyllium . . . . . . . . . . . . . . . . . . 53PULMICORT RESPULES . . . 44PULMOZYME . . . . . . . . . . . . . 48PURINETHOL . . . . . . . . . . . . . . 4pyrantel pamoate . . . . . . . . . . 28pyrazinamide . . . . . . . . . . . . . . 29pyrethrins/piperonyl butoxide

liquid shampoo . . . . . . . . . 53pyrethrins/piperonyl butoxide

shampoo . . . . . . . . . . . . . . 18PYRIDIUM . . . . . . . . . . . . . . . . 45pyridostigmine . . . . . . . . . . . . . 15pyridostigmine

extended-release . . . . . . . 15pyrilamine tan/phenyleph tan 43pyrimethamine . . . . . . . . . . . . 32

QQUESTRAN . . . . . . . . . . . . . . . 11QUESTRAN-LIGHT . . . . . . . . . 11quinapril . . . . . . . . . . . . . . . . . . . 8quinapril/hydrochlorothiazide . 8

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Index of Covered DrugsQUINIDINE GLUCONATE

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

release . . . . . . . . . . . . . . . . . 9quinidine sulfate . . . . . . . . . . . . 9QUINIDINE SULFATE

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

release . . . . . . . . . . . . . . . . . 9QVAR REDIHALER . . . . . . . . . 43

RR-TANNAMINE . . . . . . . . . . . . 40raloxifene . . . . . . . . . . . . . . . . . 24ramipril . . . . . . . . . . . . . . . . . . . . 8RANEXA . . . . . . . . . . . . . . . . . 12ranitidine . . . . . . . . . . . . . . . . . 26ranitidine syrup . . . . . . . . . . . . 26ranolazine . . . . . . . . . . . . . . . . 12RAPAMUNE. . . . . . . . . . . . . . . . 6RAVICTI . . . . . . . . . . . . . . . . . . 49RAZADYNE . . . . . . . . . . . . . . . 12REBETOL/COPEGUS . . . . . . 31RECOMBIVAX HB . . . . . . . . . 49rectal crm, suppositories . . . . 53RECTIV . . . . . . . . . . . . . . . . . . . 19REESE’S PINWORM

MEDICINE . . . . . . . . . . . . . 28REGLAN . . . . . . . . . . . . . . . . . 25regorafenib . . . . . . . . . . . . . . . . 5REGRANEX . . . . . . . . . . . . . . . 19RELAFEN . . . . . . . . . . . . . . . . . 13RELENZA. . . . . . . . . . . . . . . . . 31RELION 70/30 . . . . . . . . . . . . 23RELION N . . . . . . . . . . . . . . . . 23RELION R . . . . . . . . . . . . . . . . 23RENVELA . . . . . . . . . . . . . . . . 48repaglinide . . . . . . . . . . . . . . . . 24REQUIP . . . . . . . . . . . . . . . . . . 15RETIN-A . . . . . . . . . . . . . . . . . . 16REVATIO . . . . . . . . . . . . . . . . . 12REVLIMID . . . . . . . . . . . . . . . . . 6ribavirin . . . . . . . . . . . . . . . . . . . 31RID SHAMPOO . . . . . . . . .18, 53RIDAURA . . . . . . . . . . . . . . . . . 32rifabutin . . . . . . . . . . . . . . . . . . 29

RIFADIN . . . . . . . . . . . . . . . . . . 29rifampin . . . . . . . . . . . . . . . . . . 29rifapentine . . . . . . . . . . . . . . . . 29RILUTEK . . . . . . . . . . . . . . . . . 13riluzole . . . . . . . . . . . . . . . . . . . 13rimantadine . . . . . . . . . . . . . . . 31riociguat . . . . . . . . . . . . . . . . . . 12RISA-BID . . . . . . . . . . . . . .28, 53RISAQUAD . . . . . . . . . . . . .28, 53rivaroxaban . . . . . . . . . . . . . . . . 7rivastigmine . . . . . . . . . . . . . . . 12rizatriptan . . . . . . . . . . . . . . . . . 15RMS . . . . . . . . . . . . . . . . . . . . . 14ROBAXIN . . . . . . . . . . . . . . . . . 33ROBINUL . . . . . . . . . . . . . . . . . 27ROBITUSSIN . . . . . . . . 40-42, 52ROBITUSSIN CF . . . . . . . .41, 52ROBITUSSIN DM . . . . . . .41, 52ROBITUSSIN LIQ

CGH/ALRG . . . . . . . . . . . . 42ROBITUSSIN LIQ

CGH/CLD . . . . . . . . . .40, 42ROBITUSSIN LIQ

CGH/CONG . . . . . . . . . . . 41ROBITUSSIN LIQ

HD/CHST . . . . . . . . . . . . . 42ROBITUSSIN LIQ

PED NGHT . . . . . . . . . . . . 42ROBITUSSIN PE . . . . . . . .41, 52ROBITUSSIN PED LIQ CGH/

COLD . . . . . . . . . . . . . . . . . 40ROBITUSSIN PED SYP . . . . . 41ROBITUSSIN SYP

CHST CNG . . . . . . . . . . . . 41ROBITUSSIN SYP MAX-ST . . 41ROCALTROL . . . . . . . . . . . . . . 45ROCALTROL SOLUTION . . . 45rolapitant . . . . . . . . . . . . . . . . . 26RONDEC DM . . . . . . . . . . . . . 42RONDEC DM DROPS . . . . . . 42RONDEC DROPS . . . . . . . . . . 40RONDEC SYRUP . . . . . . . . . . 40ropinirole . . . . . . . . . . . . . . . . . 15ROWASA . . . . . . . . . . . . . . . . . 27ROXICODONE . . . . . . . . . . . . 14RUBRACA . . . . . . . . . . . . . . . . . 7

rucaparib . . . . . . . . . . . . . . . . . . 7ruxolitinib . . . . . . . . . . . . . . . . . . 5RYDAPT . . . . . . . . . . . . . . . . . . . 5RYNA-12 S . . . . . . . . . . . . . . . 43RYNATAN PEDIATRIC SUSP 40RYNATUSS PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 42RYTHMOL . . . . . . . . . . . . . . . . . 9

Ssacubitril/valsartan . . . . . . . . . . 9SAL-TROPINE . . . . . . . . . . . . . 28SALAGEN . . . . . . . . . . . . . . . . 21salicylic acid . . . . . . . 16, 18, 54salicylic acid 17%/

collodion . . . . . . . . . . .18, 54saline nasal spray 0.65% . . . . 21salsalate . . . . . . . . . . . . . . . . . . 33SANCTURA . . . . . . . . . . . . . . . 45SANDIMMUNE . . . . . . . . . . . . . 6SANDOSTATIN . . . . . . . . . . . . . 6SANTYL . . . . . . . . . . . . . . . . . . 19sapropterin . . . . . . . . . . . . . . . . 25sapropterin powder . . . . . . . . 25sargramostim. . . . . . . . . . . . . . . 7sarilumab . . . . . . . . . . . . . . . . . 32SAVAYSA . . . . . . . . . . . . . . . . . . 7SAVELLA . . . . . . . . . . . . . . . . . 33SCALPICIN . . . . . . . . . . . . . . . 18scopolamine . . . . . . . . . . . . . . 38SEASONALE . . . . . . . . . . . . . . 34SECTRAL . . . . . . . . . . . . . . . . . . 9secukinumab . . . . . . . . . . . . . . 32SEDAPAP . . . . . . . . . . . . . . . . . 13SEGLUROMET . . . . . . . . . . . . 23selegiline . . . . . . . . . . . . . . . . . 15selenium sulfide . . . . . . . . . . . 19SELSUN . . . . . . . . . . . . . . . . . . 19sennosides . . . . . . . . . . . . . . . 25SENOKOT . . . . . . . . . . . . . . . . 25SENSIPAR . . . . . . . . . . . . . . . . 48SEROMYCIN . . . . . . . . . . . . . . 28sevelamer . . . . . . . . . . . . . . . . . 48SHINGRIX . . . . . . . . . . . . . . . . 50SIGNIFOR . . . . . . . . . . . . . . . . . 6sildenafil . . . . . . . . . . . . . . . . . . 12

69



SILVADENE . . . . . . . . . . . . . . . 16silver sulfadiazine . . . . . . . . . . 16simethicone . . . . . . . . . . . .26, 53simvastatin . . . . . . . . . . . . . . . . 11SINEMET . . . . . . . . . . . . . . . . . 15SINEMET CR . . . . . . . . . . . . . . 15SINGULAIR . . . . . . . . . . . . . . . 44sirolimus . . . . . . . . . . . . . . . . . . . 6SIRTURO . . . . . . . . . . . . . . . . . 31sodium chloride for nebulizer 48sodium chloride hypertonic . 39sodium citrate/citric acid . . . . 45sodium phenylbutyrate . . . . . 49sodium phosphate

monobasic . . . . . . . . . . . . . 44sodium polystyrene sulfonate 12SOLIQUA . . . . . . . . . . . . . . . . . 22somatropin . . . . . . . . . . . . . . . . 24SOMAVERT . . . . . . . . . . . . . . . 25sonidegib . . . . . . . . . . . . . . . . . . 7sorafenib . . . . . . . . . . . . . . . . . . 5SORIATANE . . . . . . . . . . . . . . . 18sotalol . . . . . . . . . . . . . . . . . . . . . 9sotalol AF . . . . . . . . . . . . . . . . . . 9spacers . . . . . . . . . . . . . . . . . . . 48spinosad . . . . . . . . . . . . . . . . . 18spironolactone. . . . . . . . . . . . . 10spironolactone/

hydrochlorothiazide . . . . . 10SPORANOX . . . . . . . . . . . . . . . 30SPRYCEL . . . . . . . . . . . . . . . . . . 4STADOL . . . . . . . . . . . . . . . . . . 14STARLIX . . . . . . . . . . . . . . . . . . 24STATUSS DM SYP . . . . . . . . . 42STEGLATRO . . . . . . . . . . . . . . 23STIOLTO RESPIMAT . . . . . . . 43STIVARGA . . . . . . . . . . . . . . . . . 5stool softeners . . . . . . . . . . . . . 53STRENSIQ . . . . . . . . . . . . . . . . 24STRIVERDI RESPIMAT . . . . . 43STROMECTOL . . . . . . . . . . . . 28STUART PRENATAL . . . . . . . 54succimer . . . . . . . . . . . . . . . . . 48sucralfate . . . . . . . . . . . . . . . . . 26sugar+orthophosphoric acid 53sulcralfate . . . . . . . . . . . . . . . . . 26

SULFACET-R . . . . . . . . . . . . . . 16sulfacetamide . . . . . . 16, 37, 38sulfacetamide/pred phos . . . 37sulfacetamide/sulfur . . . . . . . . 16sulfamethoxazole/

trimethoprim, DS . . . . . . . 30sulfasalazine . . . . . . . . . . .27, 32sulfasalazine

delayed-release . . . . . .27, 32sulindac . . . . . . . . . . . . . . .13, 33sumatriptan . . . . . . . . . . . . . . . 15sunitinib . . . . . . . . . . . . . . . . . . . 5SUPRAX . . . . . . . . . . . . . . . . . . 29SUTENT . . . . . . . . . . . . . . . . . . . 5SYLATRON . . . . . . . . . . . . . . . . 6SYMLIN . . . . . . . . . . . . . . . . . . 24SYMMETREL . . . . . . . . . .15, 31SYNAGIS . . . . . . . . . . . . . . . . . 31SYNALAR . . . . . . . . . . . . . . . . 17SYNTHROID . . . . . . . . . . . . . . 24

TT-STAT . . . . . . . . . . . . . . . . . . . 16tabloid . . . . . . . . . . . . . . . . . . . . . 4tacrolimus . . . . . . . . . . . . . . 6, 19TAFINLAR . . . . . . . . . . . . . . . . . 4TAGAMET . . . . . . . . . . . . . . . . 26TALWIN NX . . . . . . . . . . . . . . . 14TAMBOCOR . . . . . . . . . . . . . . . 9TAMIFLU . . . . . . . . . . . . . . . . . 31tamoxifen . . . . . . . . . . . . . . . . . . 5tamsulosin . . . . . . . . . . . . . . . . 44TANAFED DMX

SUSPENSION . . . . . . . . . . 43TANZEUM . . . . . . . . . . . . . . . . 24TAPAZOLE . . . . . . . . . . . . . . . . 24TARCEVA . . . . . . . . . . . . . . . . . . 4TARGRETIN . . . . . . . . . . . . . . . . 6TASIGNA . . . . . . . . . . . . . . . . . . 5TASMAR . . . . . . . . . . . . . . . . . . 15TECFIDERA . . . . . . . . . . . . . . . 15teduglutide . . . . . . . . . . . . . . . . 28TEMODAR . . . . . . . . . . . . . . . . . 4TEMOVATE . . . . . . . . . . . . . . . 17temozolomide . . . . . . . . . . . . . . 4TENEX . . . . . . . . . . . . . . . . . . . . 8

TENIVAC . . . . . . . . . . . . . . . . . 50TENORETIC . . . . . . . . . . . . . . . 9TENORMIN . . . . . . . . . . . . . . . . 9TERAZOL 3/7 . . . . . . . . . . . . . 36terazosin . . . . . . . . . . . . . . . . 8, 44terbinafine . . . . . . . . . . . . .18, 30terbutaline . . . . . . . . . . . . . . . . 44terconazole . . . . . . . . . . . . . . . 36teriflunomide . . . . . . . . . . . . . . 15tesamorelin . . . . . . . . . . . . . . . 24TESSALON . . . . . . . . . . . . . . . 39TESTOSTERONE 1% TOPICAL

GEL . . . . . . . . . . . . . . . . . . 22testosterone cypionate . . . . . . 22testosterone enanthate . . . . . . 22testosterone gel topical tube,

packet, and pump bottle . 22tet tox-diph-acell pertuss ad . 50TET/DIP TOX INJ . . . . . . . . . . 50tetanus immune globulin

(human) . . . . . . . . . . . . . . . 50tetanus-diphtheria toxoids

(td) . . . . . . . . . . . . . . . . . . . 50tetrabenazine . . . . . . . . . . . . . . 16tetrahydrozoline/zinc sulfate . 36thalidomide . . . . . . . . . . . . . . . . 6THALOMID . . . . . . . . . . . . . . . . 6THEO-24 . . . . . . . . . . . . . . . . . 44THEOCHRON . . . . . . . . . . . . . 44theophylline . . . . . . . . . . . . . . . 44theophylline

extended-release . . . . . . . 44thioguanine . . . . . . . . . . . . . . . . 4THYROLAR . . . . . . . . . . . . . . . 24TIAZAC . . . . . . . . . . . . . . . . . . . 10ticagrelor . . . . . . . . . . . . . . . . . . 7TIGAN . . . . . . . . . . . . . . . . . . . . 26TIKOSYN . . . . . . . . . . . . . . . . . . 9timolol . . . . . . . . . . . . . . . . . . . . 37timolol maleate . . . . . . . . . . . . 37TIMOPTIC . . . . . . . . . . . . . . . . 37TIMOPTIC XE . . . . . . . . . . . . . 37TINACTIN . . . . . . . . . . . . . .18, 51tiotropium/olodaterol . . . . . . . 43tizanidine . . . . . . . . . . . . . . . . . 33TOBRADEX . . . . . . . . . . . . . . . 37

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Index of Covered Drugstobramycin . . . . . . . . . 37, 38, 48tobramycin neb soln . . . . . . . . 48tobramycin/dexamethasone . 37TOBREX . . . . . . . . . . . . . . . . . . 38tolazamide . . . . . . . . . . . . . . . . 24tolbutamide . . . . . . . . . . . . . . . 24tolcapone . . . . . . . . . . . . . . . . . 15TOLINASE . . . . . . . . . . . . . . . . 24tolnaftate . . . . . . . . . . . . . .18, 51tolterodine . . . . . . . . . . . . . . . . 45topical antibacterials . . . . . . . . 52topotecan . . . . . . . . . . . . . . . . . . 7TOPROL XL . . . . . . . . . . . . . . . . 9TORADOL . . . . . . . . . . . . . . . . 13toremifene . . . . . . . . . . . . . . . . . 5torsemide . . . . . . . . . . . . . . . . . 10TOUJEO SOLOSTAR . . . . . . . 22TRACLEER . . . . . . . . . . . . . . . 12tramadol . . . . . . . . . . . . . . . . . . 13trametinib . . . . . . . . . . . . . . . . . . 5TRANDATE . . . . . . . . . . . . . . . . 9trandolapril . . . . . . . . . . . . . . . . . 8tranexamic acid . . . . . . . . . . . . 36TRECATOR . . . . . . . . . . . . . . . 29TRENTAL . . . . . . . . . . . . . . . . . . 8tretinoin . . . . . . . . . . . . . . . . 7, 16TRI RX . . . . . . . . . . . . . . . . . . . 47TRI-FED X. . . . . . . . . . . . . . . . . 43TRI-NORINYL . . . . . . . . . . . . . 35TRI-VI-FLOR . . . . . . . . . . . . . . . 47TRI-VI-SOL . . . . . . . . . . . . .47, 54triamcinolone . . . . . . . . . . .17, 21triamcinolone acetonide . . . . 17triamcinolone nasal spray . . . 21triamterene/

hydrochlorothiazide . . . . . 10trifluridine . . . . . . . . . . . . . . . 4, 38trifluridine/tipiracil . . . . . . . . . . . 4trihexyphenidyl . . . . . . . . . . . . 15TRILYTE . . . . . . . . . . . . . . . . . . 25trimethobenzamide . . . . . . . . 26trimethoprim . . . . . . . 30, 32, 38TRIOTANN . . . . . . . . . . . . .21, 40TRIOTANN PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 40tripolidine/pseudoephedrine 43

TRIPROL/PSE SYP . . . . . . . . 43TRIVORA . . . . . . . . . . . . . . . . . 35TROJAN . . . . . . . . . . . . . . . . . . 52trospium . . . . . . . . . . . . . . . . . . 45TRULICITY . . . . . . . . . . . . . . . . 24TRUSOPT . . . . . . . . . . . . . . . . 37TRUST NATALCARE

PAK DHA . . . . . . . . . . . . . . 46TRUSTEX . . . . . . . . . . . . . . . . . 52TUMS . . . . . . . . . . . . . . . . .52, 54TUSSI-12 S . . . . . . . . . . . . . . . 39TUSSIN DM . . . . . . . . . . . . . . . 41TYKERB . . . . . . . . . . . . . . . . . . . 5TYLENOL . . . . . . . 13, 14, 32, 54TYLENOL W/CODEINE . . . . . 14TYMLOS . . . . . . . . . . . . . . . . . 24typhoid vaccine . . . . . . . . . . . . 50

UULORIC . . . . . . . . . . . . . . . . . . 33ULTRA . . . . . . . . . . . . . . . . . . . 23ULTRA 2, ULTRAMINI . . . . . . 23ULTRAM . . . . . . . . . . . . . . . . . . 13ULTRAVATE . . . . . . . . . . . . . . . 17umeclidinium inhalation . . . . . 43UNI-HIST DROps . . . . . . . . . . 39UNIPHYL . . . . . . . . . . . . . . . . . 44UNISOM . . . . . . . . . . . . . . .39, 53UREA 10% CREAM . . . . . . . . 20UREA 10% LOTION . . . . . . . . 20urea 10%, urea 20% . . . . . . . . 20UREA 20% CREAM . . . . . . . . 20urea 40% . . . . . . . . . . . . . . . . . 20UREA 40% LOTION . . . . . . . . 20URECHOLINE . . . . . . . . . . . . . 44UREX . . . . . . . . . . . . . . . . . . . . 45uridine . . . . . . . . . . . . . . . . . . . 25UROCIT-K . . . . . . . . . . . . . . . . 45UROXATRAL . . . . . . . . . . . . . . 44URSO . . . . . . . . . . . . . . . . . . . . 28URSO FORTE . . . . . . . . . . . . . 28ursodiol . . . . . . . . . . . . . . . . . . 28UTIRA C . . . . . . . . . . . . . . . . . . 44

VVAGIFEM . . . . . . . . . . . . . . . . . 35

vaginal products . . . . . . . . . . . 51valacyclovir . . . . . . . . . . . . . . . . 31valbenazine . . . . . . . . . . . . . . . 16VALCYTE . . . . . . . . . . . . . . . . . 30valganciclovir . . . . . . . . . . . . . . 30VALTREX . . . . . . . . . . . . . . . . . 31VANCOCIN HCL . . . . . . . . . . . 30vancomycin HCl . . . . . . . . . . . 30vandetanib . . . . . . . . . . . . . . . . . 5VAQTA . . . . . . . . . . . . . . . . . . . 49varicella virus vac live for

subcutaneous . . . . . . . . . . 50VARIVAX . . . . . . . . . . . . . . . . . 50VARUBI . . . . . . . . . . . . . . . . . . 26VASERETIC . . . . . . . . . . . . . . . . 8VASOCIDIN . . . . . . . . . . . . . . . 37VASOCLEAR . . . . . . . . . . . . . . 36VASOCLEAR A . . . . . . . . . . . . 36VASOTEC . . . . . . . . . . . . . . . . . . 8VECTICAL . . . . . . . . . . . . . . . . 18VEETIDS . . . . . . . . . . . . . . . . . 30VELTASSA . . . . . . . . . . . . . . . . 12vemurafenib . . . . . . . . . . . . . . . . 5VENCLEXTA . . . . . . . . . . . . . . . 5venetoclax . . . . . . . . . . . . . . . . . 5VENTOLIN HFA . . . . . . . . . . . . 43VEPESID . . . . . . . . . . . . . . . . . . 6verapamil . . . . . . . . . . . . . .10, 15verapamil extended-release . . 10VERIO . . . . . . . . . . . . . . . . . . . . 23VERIO, VERIO FLEX, VERIO IQ,

VERIO SYNC . . . . . . . . . . . 23VERZENIO . . . . . . . . . . . . . . . . . 4VESANOID . . . . . . . . . . . . . . . . . 7VFEND . . . . . . . . . . . . . . . . . . . 30VI-DAYLIN . . . . . . . . . . . . . . . . . 54VICODIN . . . . . . . . . . . . . . . . . . 14VICODIN ES . . . . . . . . . . . . . . . 14VINATE AZ EX . . . . . . . . . . . . . 46VINATE II . . . . . . . . . . . . . . . . . 46VIROPTIC . . . . . . . . . . . . . . . . . 38VISINE . . . . . . . . . . . . . . . . . . . 54VISINE-AC . . . . . . . . . . . . . . . . 36vismodegib . . . . . . . . . . . . . . . . 7VISTOGARD . . . . . . . . . . . . . . 25vitamin A . . . . . . . . . . . . . . . . . 47

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vitamin ADC/fluoride/±iron drops . . . . . . . . . . . . . . . . . 47

vitamin B complex/ vitamin C/folic acid . . . . . . . . . . . . . . . 47

vitamin B-1 . . . . . . . . . . . . . . . . 47VITAMIN B-12 . . . . . . . . . . . . . 45vitamin B-6 . . . . . . . . . . . . . . . . 47vitamin C . . . . . . . . . . . . . . . . . 47VITAMIN D 1000 UNIT . . . . . . 45VITAMIN D 2000 UNIT . . . . . . 45vitamin D 400 IU . . . . . . . . . . . 54VITAMIN D 400 UNIT . . . . . . . 45vitamins pediatric . . . . . . .47, 54vitamins pediatric members

<3 years old . . . . . . . . . . . . 54vitamins prenatal . . . . . . . . . . . 54VIVOTIF BERNA . . . . . . . . . . . 50VOLTAREN . . . . . 13, 32, 33, 36VOLTAREN 1% TOPICAL

GEL . . . . . . . . . . . . . . . . . . 32VOLTAREN XR . . . . . . . . .13, 33voriconazole . . . . . . . . . . . . . . 30vorinostat . . . . . . . . . . . . . . . . . . 4VOSOL HC OTIC . . . . . . . . . . 20VOSOL OTIC . . . . . . . . . . . . . . 20VOTRIENT . . . . . . . . . . . . . . . . . 5

Wwarfarin . . . . . . . . . . . . . . . . . . . 7WESTCORT . . . . . . . . . . . . . . . 17WYTENSIN . . . . . . . . . . . . . . . 12

XXALATAN . . . . . . . . . . . . . . . . . 38XALKORI . . . . . . . . . . . . . . . . . . 4XARELTO . . . . . . . . . . . . . . . . . . 7XELODA . . . . . . . . . . . . . . . . . . . 4XENAZINE . . . . . . . . . . . . . . . . 16XIIDRA . . . . . . . . . . . . . . . . . . . 38XOLAIR . . . . . . . . . . . . . . . . . . 43XOPENEX RESPULES . . . . . . 44XULANE . . . . . . . . . . . . . . . . . . 35XYLOCAINE . . . . . . . . . . . .19, 21XYZAL . . . . . . . . . . . . . . . . . . . 20

Yyuvafem or estradiol vaginal

tablets . . . . . . . . . . . . . . . . . 35

ZZANAFLEX . . . . . . . . . . . . . . . 33zanamivir . . . . . . . . . . . . . . . . . 31ZANTAC . . . . . . . . . . . . . . . . . . 26ZAROXOLYN . . . . . . . . . . . . . . 10ZARXIO . . . . . . . . . . . . . . . . . . . 7ZEBETA . . . . . . . . . . . . . . . . . . . 9ZEBUTAL . . . . . . . . . . . . . . . . . 13ZEJULA . . . . . . . . . . . . . . . . . . . 6ZELBORAF . . . . . . . . . . . . . . . . 5ZENPEP . . . . . . . . . . . . . . . . . . 27ZENTANE . . . . . . . . . . . . . . . . . 16ZESTORETIC . . . . . . . . . . . . . . 8ZESTRIL . . . . . . . . . . . . . . . . . . . 8ZETIA . . . . . . . . . . . . . . . . . . . . 11ZIAC . . . . . . . . . . . . . . . . . . . . . . 9ZINBRYTA . . . . . . . . . . . . . . . . 15zinc . . . . . . . . . . . . . . . . . . .36, 47ZITHROMAX . . . . . . . . . . . . . . 29ZOCOR. . . . . . . . . . . . . . . . . . . 11ZOFRAN . . . . . . . . . . . . . . . . . . 26ZOFRAN ODT . . . . . . . . . . . . . 26ZOHYDRO ER . . . . . . . . . . . . . 14ZOLINZA . . . . . . . . . . . . . . . . . . 4ZOMACTON . . . . . . . . . . . . . . 24ZORTRESS . . . . . . . . . . . . . . . . 6ZOSTAVAX . . . . . . . . . . . . . . . . 50zoster vaccine live . . . . . . . . . . 50zoster vaccine recombinant

adjuvanted . . . . . . . . . . . . . 50ZOVIA 1/35 . . . . . . . . . . . . . . . 34ZOVIA 1/50 . . . . . . . . . . . . . . . 34ZOVIRAX . . . . . . . . . . . . . . . . . 31ZYDELIG . . . . . . . . . . . . . . . . . . 4ZYKADIA . . . . . . . . . . . . . . . . . . 4ZYLOPRIM . . . . . . . . . . . . . . . . 33ZYRTEC . . . . . . . . . . . . . . .20, 51ZYRTEC CHEWABLE

TABLET . . . . . . . . . . . . . . . 20ZYRTEC D . . . . . . . . . . . . . . . . 51ZYRTEC-D . . . . . . . . . . . . . . . . 21

ZYTIGA . . . . . . . . . . . . . . . . . . . 5ZYVOX . . . . . . . . . . . . . . . . . . . 31

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“My Medications” worksheetTake this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

Name of Medicine and Strength

Drug Tier

I Take This Medicine For Directions Doctor

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

preferred drug list (pdl) - uhccommunityplan.com · el coordinador de la sección 1557 será la...

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