preferred drug list (pdl) - uhccommunityplan.com€¦ · preferred drug list (pdl) rhode island ......

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

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

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

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

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

[email protected]

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

If you need help with your complaint, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, Monday through Friday, 8:00 a.m. to 6:00 p.m.

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

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

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

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

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

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

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free member phone number listed on your health plan member ID card, TTY 711, Monday through Friday, 8:00 a.m. to 6:00 p.m.

CSRI15MC4116789_000

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

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

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

[email protected]

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

Si usted necesita ayuda con su queja, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, de lunes a viernes, de 8:00 a.m. a 6:00 p.m.

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

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

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

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

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

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

Ofrecemos servicios gratuitos para ayudarle a comunicarse con nosotros. Tales como, cartas en otros idiomas o en letra grande. O bien, puede solicitar un intérprete. Para pedir ayuda, por favor llame al número de teléfono gratuito para miembros que aparece en su tarjeta de identificación del plan de salud, TTY 711, de lunes a viernes, de 8:00 a.m. a 6:00 p.m.

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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? (We call the Preferred Drug List the

“Drug List” for short.)

The drugs on Preferred 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:

· your doctor or other prescriber says you need them to get better or stay healthy,

and

· you fill the prescription at a UnitedHealthcare Community Plan network

pharmacy.

UnitedHealthcare may have additional steps to access certain drugs (see question <#5>

below).

You can also see an up-to-date drug list on our website at

<myuhc.com/CommunityPlan> or call Member Services at <1-800-587-5187> TTY 711.

2 Does the Drug List ever change?

Yes. UnitedHealthcare Community Plan may add or remove drugs on the Drug List

during the year. Generally, the Drug List will only change if:

· a cheaper drug comes along that works as well as a drug on the Drug List now, or

· 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 always check the up-to-date Drug List online at <myuhc.com/CommunityPlan>

You can also call Member Services to check the current Drug List at <1-800-587-5187,

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

will take it off the Drug List right away. We will 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

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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 <4-51>. You can also get more information by visiting our website at

<myuhc.com/CommunityPlan>. We have posted online documents that explain our prior

authorization and step therapy restrictions. You may also call 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 <4-51> 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.

To search by medical condition, find the section labeled “List of drugs by medical

condition” on pages <4-51>. 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.

To search alphabetically, go to the <Index of Covered Drugs> starting on page <52>

Find the name of your drug. The page number where you can find the drug will be next

to it.

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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. Or

· 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?

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.

11Can 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.

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13 How can you ask for an exception?

To ask for an exception, you can do one of two 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?

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

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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 <1-800-587-5187, 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 <52>

.

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

Sometimes UnitedHealthcare Community Plan limits the amount of a drug you

can get.

ST - Step therapy

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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 <4-51 in the footnotes>]

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2

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. 8Antiarrhythmics and Cardiac Glycosides . . . . . . 8Beta Blockers and Beta Blocker/Diuretic

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

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

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

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

Endocrinology . . . . . . . . . . . . . . . . . . . . . . . .21Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 21Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 21Growth Stimulating Agents. . . . . . . . . . . . . . . . . 23Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 23Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Gastrointestinal. . . . . . . . . . . . . . . . . . . . . . .24Constipation/Laxatives . . . . . . . . . . . . . . . . . . . . 24Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Emesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Gastroesophageal Reflux Disease (Gerd)/

Peptic Ulcers. . . . . . . . . . . . . . . . . . . . . . . . . . . 25Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . . 25Inflammatory Bowel Disease . . . . . . . . . . . . . . . 25Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 26Probiotic Supplementation. . . . . . . . . . . . . . . . . 26Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Infectious Diseases . . . . . . . . . . . . . . . . . . .26Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Antiprotozoals. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Antituberculosis Agents . . . . . . . . . . . . . . . . . . . 28

3

Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

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

OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Hormone Therapy/Menopause. . . . . . . . . . . . . 35Ovulation Stimulants . . . . . . . . . . . . . . . . . . . . . . 35Vaginal Infections. . . . . . . . . . . . . . . . . . . . . . . . . 35Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . .35Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 36Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Prostaglandins . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Miscellaneous Ophthalmics . . . . . . . . . . . . . . . . 37

Psychiatric. . . . . . . . . . . . . . . . . . . . . . . . . . .38 Alcohol Deterrents . . . . . . . . . . . . . . . . . . . . . . . . 38 Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Attention Deficit Hyperactivity Disorder

(ADHD) – Diagnosis required . . . . . . . . . . . . 38Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . 39Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . . 40Psychoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . 41Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Respiratory Drugs. . . . . . . . . . . . . . . . . . . . .41Antitussives, Decongestants, Expectorants

and Combinations . . . . . . . . . . . . . . . . . . . . . . 41Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Urological . . . . . . . . . . . . . . . . . . . . . . . . . . .46Symptomatic Benign Prostatic Hypertrophy . . 46Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Vitamins and Minerals . . . . . . . . . . . . . . . . .47Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . .49Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Antidotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 49Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 49Immune Thrombocytopenic Purpura . . . . . . . . 49Medical Devices. . . . . . . . . . . . . . . . . . . . . . . . . . 50Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . . 50Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Index of Covered Drugs . . . . . . . . . . . . . . . .52

4

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

ST = Step TherapySP = Specialty Pharmacy

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

Antineoplastics & Immunosuppressants

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

phosphate sodium EMCYT brand 2

lomustine GLEOSTINE brand 2melphalan ALKERAN brand 2temozolomide TEMODAR generic 1 PA, SPAntimetabolitescapecitabine XELODA generic 1 SPmercaptopurine PURINETHOL generic 1thioguanine TABLOID brand 2trifluridine/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, SPcabozantinib COMETRIQ brand 2 PA, SPcabozantinib CABOMETYX brand 2 PA, SPceritinib 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, SP

5




idelalisib ZYDELIG brand 2 PA, SPimatinib mesylate GLEEVEC generic 1 PA, QL, SPlapatinib ditosylate TYKERB brand 2 PA, SPlenvatinib LENVIMA brand 2 PA, SPmidostaurin RYDAPT brand 2 PA, SPnilotinib TASIGNA brand 2 PA, SPpalbociclib IBRANCE brand 2 PA, SPpazopanib VOTRIENT brand 2 PA, SPponatinib ICLUSIG brand 2 PA, SPregorafenib STIVARGA brand 2 PA, SPruxolitinib JAKAFI brand 2 PA, SPsorafenib NEXAVAR brand 2 PA, SPsunitinib SUTENT brand 2 PA, SPtrametinib MEKINIST brand 2 PA, SPvandetanib CAPRELSA brand 2 PA, SPvemurafenib ZELBORAF brand 2 PA, SPMiscellaneousleucovorin LEUCOVORIN generic 1 QL, tabsmesna 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

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6




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, SPImmunosuppressantsAntimetabolitesazathioprine IMURAN generic 1mycophenolate mofetil CELLCEPT generic 1mycophenolate sodium MYFORTIC generic 1Calcineurin Inhibitorscyclosporine SANDIMMUNE generic 1cyclosporine, modified NEORAL generic 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 PA, SP

cysteamine bitartrate CYSTAGON brand 2 SPetoposide VEPESID generic 1hydroxyurea DROXIA brand 2hydroxyurea HYDREA generic 1leuprolide LEUPROLIDE ACETATE generic 1 PA, SPmesna MESNEX brand 2mitotane 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

Anticoagulantsbetrixaban BEVYXXA 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 2warfarin 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 1Miscellaneous

deferasiroxEXJADEJADENU

brand 2 PA, SP

emicizumab-kxwh HEMLIBRA brand 2 PA, QL, SPpentoxifylline

extended-release TRENTAL generic 1

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Cardiovascular Agents

Ace Inhibitorsbenazepril LOTENSIN generic 1captopril CAPOTEN generic 1enalapril VASOTEC generic 1fosinopril 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 QLAngiotensin II Receptor Blocker Combinationslosartan/HCTZ HYZAAR generic 1 QLsacubitril/valsartan ENTRESTO brand 2 PA, QLAntiarrhythmics and Cardiac Glycosidesamiodarone tabs CORDARONE generic 1 200 mg and 400 mgdigoxin LANOXIN generic 1disopyramide NORPACE generic 1

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disopyramide extended-release NORPACE CR brand 2

dofetilide TIKOSYN generic 1 QLflecainide 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 genericsotalol AF BETAPACE AF generic 1Calcium Channel BlockersDihydropyridinesamlodipine NORVASC generic 1 QLfelodipine

extended-release PLENDIL generic 1 QL

nicardipine CARDENE generic 1nifedipine PROCARDIA generic 1nifedipine extended-

releaseADALAT CCPROCARDIA XL

generic 1 QL

nimodipine NIMOTOP generic 1 QL

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Nondihydropyridinesdiltiazem 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 1chlorthalidone CHLORTHALIDONE generic 1chlorothiazide DIURIL generic 1

chlorothiazide DIURIL ORAL SUSPENSION brand 2

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

hydrochlorothiazide ALDACTAZIDE generic 1

torsemide DEMADEX generic 1triamterene/

hydrochlorothiazideDYAZIDEMAXZIDE

generic 1

Lipid Lowering AgentsBile Acid Resin

cholestyramineQUESTRANQUESTRAN-LIGHT

generic 1

Only the bulk products are covered (cans).

Individual packets are not covered.

Fibratesfenofibrate LOFIBRA generic 1 STgemfibrozil LOPID generic 1

11




HMG-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

Sublingualnitroglycerin NITROSTAT generic 1Transdermalnitroglycerin NITRO-DUR generic 1 transdermal, QL Potassium-Removing Agentssodium polystyrene

sulfonate KAYEXALATE generic 1 susp (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, tabletsMiscellaneousguanabenz WYTENSIN generic 1hydralazine APRESOLINE generic 1methyldopa ALDOMET generic 1midodrine PROAMATINE generic 1minoxidil LONITEN generic 1

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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.

rivastigmineEXELON TABSEXELON PATCH

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

authorization.Amyotrophic Lateral Sclerosis (ALS)riluzole RILUTEK generic 1Analepticsarmodafinil NUVIGIL generic 1 Diagnosis Required, QLAnalgesicsBarbiturate Non-Narcotic Analgesicsbutalbital/acetaminophen/

caffeine FIORICET generic 1 QL

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

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

tramadol ULTRAM generic 1 QLNSAIDSdiclofenac potassium CATAFLAM generic 1diclofenac sodium

delayed-release VOLTAREN generic 1

diclofenac sodium extended-release VOLTAREN XR generic 1

etodolac LODINE generic 1 IR Only

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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 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 1Opioids - Narcotic Analgesicsbutalbital/apap/caff/cod FIORICET W/CODEINE generic 1 QL, 50-325-40-30 mgbutalbital/asa/caff/cod FIORINAL W/CODEINE generic 1 QLbutorphanol STADOL generic 1 nasal spray, QLcodeine sulfate generic 1 QLcodeine/acetaminophen TYLENOL W/CODEINE 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 QLmorphine RMS generic 1 QLmorphine MSIR generic 1 QLmorphine

extended-release MS CONTIN generic 1 PA, QL

oxycodone OXYFAST generic 1 soln, QLoxycodone ROXICODONE generic 1 tabs, QLoxycodone/

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

oxycodone/aspirin PERCODAN generic 1 QL

14




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

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

caffeineMIGERGOT

SUPPOSITORIES brand 2 QL

Selective Serotonin Agonistsnaratriptan AMERGE generic 1 ST

rizatriptanMAXALTMAXALT MLT

generic 1 QL

sumatriptan IMITREX generic 1 QL

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

Migraine Prophylactic Therapyamitriptyline ELAVIL generic 1

divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1

Members ≥ 8 years of age will require prior

authorization.divalproex sodium

delayed-release DEPAKOTE generic 1 Minimum age 2

propranolol INDERAL generic 1 IR onlyverapamil CALAN generic 1Multiple 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

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

extended-release SINEMET CR generic 1

entacapone COMTAN generic 1pramipexole MIRAPEX generic 1ropinirole REQUIP generic 1selegiline ELDEPRYL generic 1tolcapone TASMAR generic 1trihexyphenidyl ARTANE generic 1Seizurescarbamazepine TEGRETOL generic 1carbamazepine

extended-releaseCARBATROLTEGRETOL-XR generic 1

clobazam ONFI brand 2 Diagnosis Required, QLclonazepam KLONOPIN generic 1 tabs

divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1


authorization. divalproex sodium


ethosuximide ZARONTIN generic 1felbamate FELBATOL generic 1 QL, tablets

felbamate oral susp FELBATOL generic 1

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

authorization. gabapentin NEURONTIN generic 1 caps and tabs onlylamotrigine LAMICTAL generic 1 QL

lamotrigine chew dispersable tab LAMICTAL CD CHEW TAB generic 1


authorization.lamotrigine starter kit LAMICTAL STARTER KIT brand 2

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

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

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phenobarbital PHENOBARBITAL generic 1phenytoin DILANTIN INFATABS generic 1phenytoin sodium

extendedDILANTINPHENYTEK

generic 1

primidone MYSOLINE generic 1rufinamide BANZEL brand 2 Diagnosis Required, QL

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

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

topiramate TOPAMAX generic 1 QL

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

authorization.valproic acid DEPAKENE generic 1vigabatrin powd pack SABRIL brand 2 PA, SPzonisamide ZONEGRAN generic 1 QLMiscellaneoustetrabenazine 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 2benzoyl 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

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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 1CorticosteroidsLow Potencyalclometasone ACLOVATE generic 1 0.05% crm/oint

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

fluocinolone acetonide SYNALAR generic 1 soln/crm 0.01% hydrocortisone CORTIZONE generic 1 crm, oint, lot OTChydrocortisone HYTONE generic 1 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

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betamethasone augmented dip DIPROLENE AF generic 1 crm 0.05%

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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 creamFungal 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 OTCPsoriasis acitretin SORIATANE generic 1 oral caps, PAcalcipotriene DOVONEX generic 1 crm/oint, STcalcipotriene DOVONEX generic 1 solncalcitriol VECTICAL generic 1

salicylic acidCOMPOUND W DUOFILM

generic 1 liquid 17%

salicylic acid SCALPICIN generic 1 liquid 3%Rosacea

metronidazoleMETROCREAMMETROGEL

generic 1

metronidazole METROLOTION generic 1 QL

19




Scabies and Pediculosiscrotamiton EURAX brand 2permethrin 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 1Miscellaneousaluminum acetate brand 2 soln/cream, OTC

ammonium lactateAMLACTIN 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, OTCchloroxine CAPITROL generic 1

emollientsE-OINTMENTDERMAPHOR OINTMENTGLYCERIN TOPICAL

brand 2

fluorouracil 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% creamselenium sulfide SELSUN generic 1 lotion 2.5%

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

20




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

urea 40% UREA 40% LOTION generic 1 lotion

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

brand 2

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 6.5%, OTCneomycin/polymyxin B/

hydrocortisone CORTISPORIN OTIC generic 1 otic

ofloxacin FLOXIN OTIC generic 1NoseAntihistamines - First Generation, Sedatingchlorpheniramine

extended-release CHLOR-TRIMETON ALLERGY generic 1 12 mg, OTC

chlorpheniramine maleate CHLOR-TRIMETON SYRUP generic 1 2 mg/5 ml, OTCclemastine CLEMASTINE generic 1cyproheptadine CYPROHEPTADINE generic 1diphenhydramine generic 1diphenhydramine BENADRYL generic 1 OTChydroxyzine HCL ATARAX generic 1hydroxyzine pamoate VISTARIL generic 1Antihistamines - Second Generation, Nonsedatingcetirizine ZYRTEC generic 1 OTC

cetirizine chew tab ZYRTEC CHEWABLE TAB-LET generic 1

OTC, Members ≥ 8 years of age will require prior

authorization.levocetirizine XYZAL generic 1 tabsloratadine ALAVERT-D generic OTCNasal Steroidsfluticasone FLONASE generic 1

triamcinolone nasal spray NASACORT ALLERGY 24 HOUR brand 2 OTC

21




Miscellaneous Nasal Decongestantsoxymetazoline AFRIN generic 1 OTC

phenylephrineNEO-SYNEPHRINE DIMEATAPP DRO

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

Endocrinology

Adrenal Corticosteroidscortisone acetate generic 1dexamethasone DECADRON generic 1fludrocortisone FLORINEF generic 1hydrocortisone CORTEF generic 1methylprednisolone MEDROL generic 1 4mg, 8mg, 16mg, 32mgprednisolone PRELONE generic 1 syrupprednisolone MILLIPRED brand 2 tabletsdiphenhydramine BENADRYL generic 1 OTCprednisolone 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% TOPI-CAL GEL generic 1 PA

Diabetes MellitusGlucose Elevating Agentsglucagon, human

recombinant GLUCAGON brand 2 QL

Insulin Combinationsinsulin glargine/lixisenatide SOLIQUA brand 2 PA, QL

22




Insulinsinsulin 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

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 isophane/regular HUMULIN 70/30 brand 2 OTC, QL, vialsinsulin lisopro pro/lispro HUMALOG MIX 50/50 brand 2 QL, vialsinsulin lisopro prot/lispro HUMALOG MIX 75/25 brand 2 QL, vialsinsulin lispro ADMELOG SOLOSTAR brand 2 PA, QLinsulin lispro ADMELOG VIALS brand 2 QLinsulin regular HUMULIN R brand 2 OTC, QL, vialsMiscellaneous Antidiabetic Agentsdulaglutide TRULICITY brand 2 PAlixisenatide ADLYXIN brand 2 PAMonitoring - Strips and Kits/Diabetic Supplies

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

QL for insulin dependent or pregnant members:

allow testing up to 6 times per day

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

dependent members: allow twice daily testing

Oral Agentsalogliptin NESINA generic 1 STalogliptin/metformin KAZANO generic 1 STalogliptin/pioglitazone OSENI generic 1 STacarbose PRECOSE generic 1chlorpropamide DIABINESE generic 1ertugliflozin STEGLATRO brand 2 PA, QLertugliflozin/metformin SEGLUROMET brand 2 PA, QLglimepiride AMARYL generic 1

23




glipizide GLUCOTROL generic 1glipizide extended-release GLUCOTROL XL generic 1glyburide MICRONASE generic 1glyburide, micronized GLYNASE generic 1metformin GLUCOPHAGE generic 1metformin ER GLUCOPHAGE ER generic 1metformin/glyburide GLUCOVANCE generic 1nateglinide STARLIX generic 1repaglinide PRANDIN generic 1tolazamide TOLINASE generic 1Growth Stimulating Agentsmecasermin INCRELEX brand 2 PA, SPsomatropin ZOMACTON brand 2 PA, SPOsteoporosisabaloparatide TYMLOS brand 2 PA, QL, SPalendronate FOSAMAX generic 1 QLcalcitonin-salmon FORTICAL brand 2 nasal spray, QLcalcitonin-salmon MIACALCIN brand 2 injcalcitonin-salmon MIACALCIN generic 1 nasal spray, QLetidronate DIDRONEL generic 1raloxifene EVISTA generic 1Thyroid Diseaselevothyroxine LEVOXYL generic 1levothyroxine SYNTHROID generic 1liothyronine CYTOMEL generic 1methimazole TAPAZOLE generic 1propylthiouracil PROPYLTHIOURACIL generic 1Miscellaneousasfotase alfa STRENSIQ brand 2 PA, SPcabergoline DOSTINEX generic 1cholic acid CHOLBAM brand 2 PA, QL, SPcinacalcet SENSIPAR brand 2 PA, QLdesmopressin DDAVP generic 1 QLmethylergonovine METHERGINE generic 1mifepristone KORLYM brand 2 PA, SP

nitisinone NITYR brand 2 Diagnosis Required, QL, SP

pegvisomant SOMAVERT brand 2 PA, QL, SP

sapropterin KUVAN brand 2 Diagnosis Required, QL, SP

24




sapropterin powder KUVAN POWDER FOR SOLUTION

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 40mg,

80mg, and 80-125mgmeclizine ANTIVERT generic 1metoclopramide REGLAN generic 1

ondansetronZOFRANZOFRAN ODT

generic 1 QL

prochlorperazine COMPAZINE generic 1promethazine PHENERGAN generic 1trimethobenzamide TIGAN generic 1 300 mg caps

25




Gastroesophageal 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 1

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 prior

authorization, QLomeprazole

delayed-release PRILOSEC generic 1 Capsules only, QL

pantoprazole PROTONIX generic 1ranitidine ZANTAC generic 1 150 mg tabsranitidine syrup ZANTAC generic 1sucralfate CARAFATE generic 1

sulcralfate CARAFATE SUSPENSION brand 2

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

prior authorization.Gastrointestinal Spasmdicyclomine BENTYL generic 1glycopyrrolate ROBINUL generic 1hyoscyamine sulfate LEVSIN generic 1hyoscyamine sulfate

extended-release LEVSINEX generic 1

Inflammatory Bowel Diseasebudesonide ENTOCORT EC generic 1 Diagnosis Required, QLmesalamine ROWASA generic 1 enema onlymesalamine

extended-release APRISO brand 2

olsalazine sodium DIPENTUM brand 2sulfasalazine AZULFIDINE generic 1

26




sulfasalazine delayed-release AZULFIDINE EN-TABS generic 1

Pancreatic Enzymes

pancrelipaseCREONCREON 3000 UNIT

brand 2 QL

pancrelipase ZENPEP brand 2Probiotic Supplementationacidophilus ACIDOPHILUS brand 2 caps and tabs, OTC

acidophilus/bifidus ACIDOPHILUS/ BIFIDUS WAFER brand 2 OTC

acidophilus/citrus pectin ACIDOPHILUS/ CITRUS PECTIN brand 2 tabs, OTC

acidophilus/pectin ACIDOPHILUS/PECTIN brand 2 caps, OTC

probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEXFLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

brand 2 OTC

Miscellaneousmisoprostol CYTOTEC generic 1teduglutide GATTEX brand 2 PA, QL, SPursodiol ACTIGALL generic 1

Infectious Diseases

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

27




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

pyrantel pamoate PIN-X brand 2 chewable tablets, suspension

AntibacterialsAntituberculosis Agentsethambutol MYAMBUTOL generic 1isoniazid ISONIAZID generic 1pyrazinamide PYRAZINAMIDE generic 1rifampin RIFADIN generic 1Cephalosporins - First Generationcefadroxil DURICEF generic 1cephalexin KEFLEX generic 1 tabs are not coveredCephalosporins - Second Generationcefaclor CECLOR generic 1cefprozil CEFZIL generic 1cefuroxime axetil CEFTIN generic 1 tabsCephalosporins - Third Generationcefdinir OMNICEF generic 1Fluoroquinolonesciprofloxacin 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 ethylsuccinate E.E.S. generic 1

erythromycin stearate ERYTHROCIN generic 1erythromycin/sulfisoxazole PEDIAZOLE generic 1Penicillins

amoxicillin AMOXICILLIN generic 1 Except 500 mg and 875 mg film-coated tabs.

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

28




Sulfonamidessulfamethoxazole/

trimethoprim, DSBACTRIMBACTRIM DS

generic 1

Tetracyclines

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

minocycline MINOCIN generic 1 capsules, except 75 mg, minimum age 9

Miscellaneousvancomycin HCl VANCOCIN HCL generic 1 cap, STAntifungalsclotrimazole MYCELEX generic 1 trochesfluconazole DIFLUCAN generic 1 QLgriseofulvin microsize GRIFULVIN V generic 1griseofulvin ultramicrosize GRIS-PEG generic 1itraconazole SPORANOX generic 1 PA, QLketoconazole NIZORAL generic 1nystatin MYCOSTATIN generic 1terbinafine LAMISIL generic 1 QLvoriconazole VFEND generic 1 PAAntiprotozoalsatovaquone MEPRON generic 1 PAbenznidazole BENZNIDAZOLE brand 2 PA, QLmiltefosine IMPAVIDO brand 2 PApentamidine isethionate

for nebulization NEBUPENT brand 2

Antituberculosis Agentscycloserine SEROMYCIN generic 1rifabutin MYCOBUTIN generic 1 QLAntiviralsCytomegalovirus Treatmentganciclovir CYTOVENE generic 1valganciclovir VALCYTE generic 1 tabs onlyHepatitis Treatmentdasabuvir/ombitasvir/

paritaprevir/ritonavirVIEKIRAVIEKIRA XR

brand 2 PA, SP, preferred for Genotype 1

elbasvir/grazoprevir ZEPATIER brand 2 PA, SP, preferred for Genotypes 1 & 4

entecavir BARACLUDE generic 1 SP

29




interferon alfa-2b INTRON A brand 2 PA, SP

ledipasvir/sofosbuvir HARVONI brand 2 PA, SP, preferred for Genotypes 1, 4, 5, & 6

lamivudine 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, SPombitasvir/ paritaprevir/

ritonavir TECHNIVIE brand 2 PA, SP, preferred for Genotype 4

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

sofosbuvir/velpatasvir EPCLUSA brand 2 PA, SP, preferred forGenotypes 1 & 2

Herpes Treatmentacyclovir ZOVIRAX generic 1 caps/susp/tabs onlydocosanol ABREVA OTC CREAM brand 2valacyclovir VALTREX generic 1Influenza Treatmentamantadine SYMMETREL generic 1 except tabsoseltamivir TAMIFLU generic 1 capsules, QLrimantadine FLUMADINE generic 1zanamivir RELENZA brand 2 QLIntegrase Inhibitorsdolutegravir TIVICAY brand 2raltegravir ISENTRESS brand 2raltegravir ISENTRESS CHEWABLE brand 2 chewable tabletraltegravir ISENTRESS HD brand 2

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

authorization.Non-Nucleoside Reverse Transcriptase Inhibitorsdelavirdine RESCRIPTOR brand 2efavirenz SUSTIVA brand 2etravirine INTELENCE brand 2nevirapine VIRAMUNE generic 1nevirapine ER VIRAMUNE XR brand 2rilpivirine EDURANT brand 2Nucleoside Analogues Nucleoside Reverse - Transcriptase Inhibitors/and Combinationsabacavir ZIAGEN generic 1abacavir/lamivudine EPZICOM generic 1

30




abacavir/lamivudine/ zidovudine TRIZIVIR generic 1

didanosine VIDEX brand 2didanosine

delayed-release VIDEX EC generic 1

efavirenz/lamivudine/tenofovir disoproxil fumarate

SYMFISYMFI LO

brand 2 QL

emtricitabine EMTRIVA brand 2emtricitabine/rilpivirine/

tenofovir COMPLERA brand 2 PA

lamivudine EPIVIR generic 1lamivudine/tenofovir

disoproxil fumarate CIMDUO brand 2 QL

lamivudine/zidovudine COMBIVIR generic 1stavudine ZERIT generic 1zalcitabine HIVID brand 2zidovudine RETROVIR generic 1Nucleoside/Nucleotide Reverse - Transcriptase Inhibitor Combinationefavirenz/emtricitabine/

tenofovir ATRIPLA brand 2

emtricitabine/rilpivirine/tenofovir ODEFSEY brand 2

emtricitabine/tenofovir alafenamide DESCOVY brand 2 QL

emtricitabine/tenofovir disoproxil TRUVADA brand 2

Nucleotide Analogues Nucleotide Reverse - Transcriptase Inhibitortenofovir VIREAD generic 1Protease Inhibitorsatazanavir REYATAZ generic 1

atazanavir REYATAZ POWDER PACKET brand 2


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

31




ritonavir NORVIR brand 2saquinavir mesylate INVIRASE brand 2tipranavir APTIVUS brand 2Miscellaneousabacavir/dolutegravir/

lamivudine TRIUMEQ brand 2 QL

cobicistat TYBOST brand 2 QLcobicistat/elvitegravir/

emtricitabine/tenofovir STRIBILD brand 2 PA, QL

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

emtricitabine/tenofovir alafenamide fumarate

GENVOYA brand 2 PA, QL

enfuvirtide FUZEON brand 2 QLmaraviroc SELZENTRY 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 ≥ or equal to 8 years of age will require

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

32




Musculoskeletal

ArthritisDisease Modifying Anti-Rheumatic Drugsadalimumab HUMIRA brand 2 PA, SPauranofin RIDAURA brand 2azathioprine IMURAN generic 1canakinumab ILARIS brand 2 PA, SPcertolizumab pegol CIMZIA brand 2 PA, SPetanercept ENBREL brand 2 PA, SPhydroxychloroquine PLAQUENIL generic 1leflunomide ARAVA generic 1methotrexate generic 1

penicillamine DEPEN TITRATABLE brand 2 Diagnosis Required, QL, SP

sarilumab 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 1 OTC

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

celecoxib CELEBREX generic 1 PA, QL

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

diclofenac potassium CATAFLAM generic 1diclofenac sodium

delayed-release VOLTAREN generic 1

diclofenac sodium extended-release VOLTAREN XR generic 1

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 QL

33




naproxen 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 1probenecid PROBENECID generic 1Skeletal Muscle RelaxantsMuscle Spasmchlorzoxazone PARAFON FORTE DSC generic 1cyclobenzaprine FLEXERIL generic 1 5mg & 10mgmethocarbamol ROBAXIN generic 1

orphenadrine ER ORPHENADRINE CITRATE TAB SR generic 1 QL

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

OB-GYN

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

acetate DEPO-PROVERA generic 1 QL

Intravaginaletonogestrel/EE NUVARING brand 2 ring, QL

ortho diaphragmORTHO COILORTHO FLATORTHO FLEX

brand 2 QL

34




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

cap PROMETRIUM generic 1 Diagnosis Required, QL

Transdermal

norelgestromin/EEORTHO EVRAXULANE

generic 1

Triphasicdesogestrel/EE CYCLESSA generic 1 QLlevonorgestrel/EE TRIVORA generic 1 QLnorethindrone

acetate/EE/iron ESTROSTEP FE generic 1 QL

norethindrone/EE ORTHO-NOVUM 7/7/7 generic 1 QLnorethindrone/EE TRI-NORINYL generic 1 QLnorgestimate/EE ORTHO TRI-CYCLEN generic 1 QLEndometriosisdanazol DANOCRINE generic 1

35




Hormone Therapy/MenopauseEstrogens - Intravaginalestrogens, conjugated PREMARIN brand 2 crmyuvafem or estradiol

vaginal tablet VAGIFEM generic 1 QL

Estrogens - Oralestradiol ESTRACE generic 1estrogens, conjugated PREMARIN brand 2estropipate OGEN generic 1Estrogens - Transdermal

estradiolCLIMARAVIVELLE

generic 1 QL

Estrogen/Progestinestrogens, conjugated/

medroxyprogesteronePREMPHASEPREMPRO

brand 2

Progestinsmedroxyprogesterone

acetate PROVERA generic 1

norethindrone acetate AYGESTIN generic 1Ovulation Stimulantschoriogonadotropin alfa OVIDREL brand 2 Diagnosis Required, QLchorionic gonadotropin NOVAREL brand 2 Diagnosis Required, QLVaginal InfectionsOralfluconazole DIFLUCAN generic 1 QLmetronidazole FLAGYL generic 1 tabsVaginalclindamycin CLEOCIN generic 1 crmmetronidazole METROGEL-VAGINAL generic 1miconazole MONISTAT 3 generic 1terconazole TERAZOL 3/7 generic 1 crmMiscellaneousmethylergonovine METHERGINE generic 1tranexamic acid LYSTEDA generic 1 PA

Ophthalmic

Allergyazelastine OPTIVAR generic 1 STcromolyn sodium CROLOM generic 1 QL

36




ketotifen ALAWAY OTC generic 1

naphazoline/glycerin CLEAR EYES REDNESS RELIEF generic 1

naphazoline HCL VASOCLEAR generic 1 soln 0.02%tetrahydrozoline/

zinc sulfate VISINE-AC generic 1

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

neomycin/hc CORTISPORIN generic 1 ointment

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 QL

Nonsteroidalflurbiprofen OCUFEN generic 1

ketorolacACULARACULAR LS

generic 1

Steroidaldexamethasone sodium

phosphate DEXASOL generic 1

fluorometholone FML LIQUIFILM brand 2 susp 0.1%fluorometholone FML FORTE generic 1 susp 0.25%prednisolone acetate PRED FORTE generic 1 1%prednisolone phosphate INFLAMASE FORTE generic 1 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

37




Mydriaticsatropine ISOPTO ATROPINE generic 1cyclopentolate CYCLOGYL generic 1 1%homatropine ISOPTO HOMATROPINE generic 1 5%Oralacetazolamide ACETAZOLAMIDE generic 1acetazolamide

extended-release DIAMOX SEQUELS generic 1

methazolamide NEPTAZANE generic 1Topical - Parasympathomimeticspilocarpine ISOPTO CARPINE generic 1Topical - Sympathomimeticsbrimonidine ALPHAGAN P generic 1 0.15%brimonidine ALPHAGAN generic 1 0.2%epinephrine generic 1 opthInfectionsBacterialbacitracin generic 1ciprofloxacin CILOXAN generic 1 solutionerythromycin ERYTHROMYCIN generic 1 QLgentamicin 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 1Prostaglandinslatanoprost XALATAN generic 1 QLMiscellaneous Ophthalmicscysteamine 0.44% CYSTARAN brand 2 Diagnosis Required,

QL, SPsodium chloride

hypertonic MURO 128 generic 1 soln 5%

38




Psychiatric

Alcohol Deterrentsacamprosate CAMPRAL brand 2disulfiram ANTABUSE generic 1naltrexone REVIA generic 1AnxietyBenzodiazepinesalprazolam XANAX generic 1 QL, IR onlychlordiazepoxide LIBRIUM generic 1clonazepam KLONOPIN generic 1 not wafersclorazepate TRANXENE generic 1diazepam VALIUM generic 1 QLlorazepam ATIVAN generic 1 QLoxazepam SERAX generic 1 QLMiscellaneousbuspirone BUSPAR generic 1fluvoxamine LUVOX generic 1Attention Deficit Hyperactivity Disorder (ADHD) – Diagnosis required amphetamine/

dextroamphetamine mixed salts

ADDERALL generic 1 Age Limits Apply, QL

amphetamine/ dextroamphetamine mixed salts extended-release

ADDERALL XR brand 2 Age Limits Apply, QL

guanfacine ER INTUNIV generic 1 Age Limits Apply, QLmethylphenidate RITALIN generic 1 tabs only, QLmethylphenidate

extended-releaseMETADATE CD METADATE ER

generic 1 Age Limits Apply, QL

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

20 mg, 30 mg, 40 mg

methylphenidate HCL ER 24hr generic 1

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

54 mg tablets, Mallinckrodt and Kremers

Urban labelers

39




Bipolar Disorderdivalproex sodium

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

authorization.divalproex sodium


lithium carbonate LITHIUM CARBONATE generic 1lithium carbonate

extended-releaseESKALITH CR LITHOBID

generic 1

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

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

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

extended-release WELLBUTRIN SR generic 1 QL

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

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

40




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

InsomniaBenzodiazepinesflurazepam DALMANE generic 1 QL

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

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

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

naloxone NARCAN NASAL SPRAY brand 2naloxone NALOXONE INJ generic 1 QLnaltrexone REVIA generic 1PsychosesAtypicals

aripiprazole ABILIFY TABLETS generic 1

Age Limit Applies, tablets, PA, QL, Certain daily doses require half

tablet dosing:5 mg once daily – must

be dosed as 10 mg tablet,

½ tab once daily10 mg once daily – must


½ tab once daily15 mg once daily – must


½ tab once dailyaripiprazole ER injection ABILIFY MAINTENA brand 2 Age Limit Applies, PA, QLaripiprazole injection ARISTADA brand 2 PA, QL

41




clozapine CLOZARIL generic 125mg, 50mg, 100mg

only, Age Limit Applies, QL

olanzapine ZYPREXA generic 1 Age Limit Applies, tablets, QL

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

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

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

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

authorization.ziprasidone GEODON generic 1 Age Limit Applies, QLSmoking Cessationnicotine NICODERM CQ generic 1 patches, QLnicotine polacrilex gum NICORETTE OTC generic 1 QLnicotine polacrilex lozenge COMMITT OTC generic 1 QLvarenicline CHANTIX brand 2 PA, QLMiscellaneouschlorpromazine THORAZINE generic 1fluphenazine PROLIXIN generic 1fluphenazine decanoate PROLIXIN DECANOATE generic 1haloperidol HALDOL generic 1haloperidol decanoate HALDOL DECANOATE generic 1loxapine LOXITANE generic 1perphenazine TRILAFON generic 1pimozide ORAP generic 1thiothixene NAVANE generic 1trifluoperazine STELAZINE generic 1

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

phenylephrineDIMETAPP CLD ELX/

ALLERGY generic 1

brompheniramine/ pseudoephedrine

ACCUHIST DROPS UNI-HIST DROPS

generic 1

42




brompheniramine/ pseudoephedrine/ dextromethorphan

BROMFED DM generic 1 syrup

chlorphen tan/pyrilamine tan/PE tan

TRIOTANN PEDIATRIC SUSP

R-TANNAMINEgeneric 1 susp

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

chlorpheniramine/ dextromethorphan

ROBITUSSIN PED LIQ CGH/COLD

ROBITUSSIN LIQ CGH/CLD

DIMETAPP SYP CGH/CLDCORICIDIN TAB

CGH/CLD

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/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 DXRESPERAL-DM

generic 1

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

43




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 SYP CHST CNG generic 1 syrup 100 mg/5 ml

guaifenesin ROBITUSSIN generic 1 OTCguaifenesin

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

phenylephrine/ brompheniramine/ dextromethorphan

generic 1 OTC

phenylephrine/ chlorpheniramine/ dextromethorphan

RONDEC DMSTATUSS DM SYPCARDEC DM SYPMINUTUSS DR SYP

generic 1 syrup

44




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/ dextromethorphan/ guaifenesin

ROBITUSSIN LIQ CGH/CLD

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

pseudoephedrine/ acetaminophen/ dextromethorphan

MAPAP COLD TAB generic 1

pseudoephedrine/ chlorpheniramine/ dextromethorphan

PEDIACARE LIQ MULTI-SY

ROBITUSSIN LIQ PED NGHT

generic 1

pseudoephedrine/ dextromethorphan/guaifenesin

MULTI SYMPTOM TAB COLD RLF generic 1

pseudoephedrine/ iburprofen

CHILD IBUPRO SUS COLD

IBUOROFEN TAB COLD/SIN

generic 1

45




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 2 QLolodaterol STRIVERDI RESPIMAT brand 2 QLInhalers - Corticosteroidsbeclomethasone QVAR REDIHALER brand 2 QL

mometasone ASMANEX HFA brand 2Patients 8 years and

older will require prior authorization

fluticasone furoate ARNUITY ELLIPTA brand 2 QLInhalers - 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 2Inhalers for Nebulization

albuterol ACCUNEB generic 1

0.63 mg/3 ml and 1.25 mg /

3 ml, Covered for members less than 8

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

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

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

authorization. QLcromolyn INTAL generic 1 soln, QL

46




ipratropium 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 liquid

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 1

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

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

47




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 OTC, QL

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

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

48




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

TRUST NATALCARE PAK DHA brand 2

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

PRUET DHA PAK SETONET PAK brand 2

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

PRUET DHAEC PAK brand 2

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

FOLTABS PAK PLUS DHA RE OB + DHA PAK brand 2

prenatal vit w/FE bisglycinate chelate-FA

VINATE II brand 2


GENTEX ADE 28-1 MG brand 2


VINATE AZ EX brand 2

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

49




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

potassium chloride extended-release

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

generic 1 tabs

potassium iodide SSKI brand 2

Miscellaneous

Anaphylaxis

epinephrineEPIPEN EPIPEN JR.

generic 1 QL

Antidotessuccimer 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

ivacaftor KALYDECO brand 2 PA, SPlumacaftor/ivacaftor ORKAMBI brand 2 PA, QL, SP

sodium chloride for nebulizer

HYPERSALNEBUSAL

generic 1

tobramycin neb soln BETHKIS brand 2 Diagnosis Required, QL, SP

Hereditary Angioedemac1 esterase inhibitor, human BERINERT brand 2 PA, SPc1 esterase inhibitor, human HAEGARDA brand 2 PA, QL, SPicatibant FIRAZYR brand 2 PA, SPHyperphosphatemiacalcium acetate generic 1 667 mg tablet onlysevelamer RENVELA generic 1 QL, STImmune Thrombocytopenic Purpuraeltrombopag PROMACTA brand 2 PA, QL, SP

50




Medical Devicesinsulin syringes QLlancets QLspacers QLMetabolic 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 AFLURIA, FLUZONE 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

51




influenza virus vaccine types a&b surface antigen

FLUVIRIN brand 2 QL

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

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

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

varicella 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

52

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

Index of Covered Drugs

Aabacavir . . . . . . . . . . . . . . . 29-31abacavir/dolutegravir/

lamivudine . . . . . . . . . . . . . 31abacavir/lamivudine . . . . .29, 30abacavir/lamivudine/

zidovudine . . . . . . . . . . . . . 30abaloparatide . . . . . . . . . . . . . 23abemaciclib . . . . . . . . . . . . . . . . 4ABILIFY MAINTENA . . . . . . . . 40ABILIFY TABLETS . . . . . . . . . 40abiraterone . . . . . . . . . . . . . . . . . 5ABREVA OTC CREAM . . . . . . 29ABSORICA . . . . . . . . . . . . . . . 16acalabrutinib . . . . . . . . . . . . . . . 4acamprosate . . . . . . . . . . . . . . 38acarbose . . . . . . . . . . . . . . . . . 22ACCUHIST DROPS . . . . . . . . 41ACCUNEB . . . . . . . . . . . . . . . . 45ACCUPRIL . . . . . . . . . . . . . . . . . 8ACCURETIC . . . . . . . . . . . . . . . 8acebutolol . . . . . . . . . . . . . . . . . 9acetaminophen . . 12, 13, 32, 44acetazolamide . . . . . . . . . . . . . 37acetazolamide

extended-release . . . . . . . 37acetic acid . . . . . . . . . . . . . . . . 20acetic acid/aluminum

acetate . . . . . . . . . . . . . . . . 20acetic acid/hydrocortisone . . 20acetylcysteine . . . . . . . . . . . . . 49acidophilus . . . . . . . . . . . . . . . 26ACIDOPHILUS/ CITRUS

PECTIN . . . . . . . . . . . . . . . 26acidophilus/bifidus . . . . . . . . . 26ACIDOPHILUS/BIFIDUS

WAFER . . . . . . . . . . . . . . . . 26acidophilus/citrus pectin . . . . 26acidophilus/pectin . . . . . . . . . 26acitretin . . . . . . . . . . . . . . . . . . . 18

ACLOVATE . . . . . . . . . . . . . . . . 17ACTIGALL . . . . . . . . . . . . . . . . 26ACTIMMUNE . . . . . . . . . . . . . . . 6ACULAR . . . . . . . . . . . . . . . . . . 36ACULAR LS . . . . . . . . . . . . . . . 36acyclovir . . . . . . . . . . . . . . . . . . 29ADACEL . . . . . . . . . . . . . . . . . . 51ADALAT CC . . . . . . . . . . . . . . . . 9adalimumab . . . . . . . . . . . . . . . 32adapalene gel . . . . . . . . . . . . . 16ADDERALL . . . . . . . . . . . . . . . 38ADDERALL XR . . . . . . . . . . . . 38ADEMPAS . . . . . . . . . . . . . . . . 11ADLYXIN . . . . . . . . . . . . . . . . . 22ADMELOG SOLOSTAR . . . . . 22ADMELOG VIALS . . . . . . . . . . 22ADVIL . . . . . . . . . . . . . . . . .13, 32afatinib . . . . . . . . . . . . . . . . . . . . 4AFINITOR . . . . . . . . . . . . . . . . . . 4AFINITOR DISPERZ . . . . . . . . . 4AFLURIA PF . . . . . . . . . . . . . . . 50AFLURIA, FLUZONE SPLT . . 50AFRIN . . . . . . . . . . . . . . . . . . . . 21AGRYLIN . . . . . . . . . . . . . . . . . . 7AIRDUO RESPICLICK . . . . . . 45AKINETON . . . . . . . . . . . . . . . . 15ALAVERT-D . . . . . . . . . . . . . . . 20ALAWAY OTC . . . . . . . . . . . . . 36albendazole . . . . . . . . . . . . . . . 26ALBENZA . . . . . . . . . . . . . . . . 26albuterol . . . . . . . . . . . . . . .45, 46albuterol sulfate . . . . . . . . . . . . 45alclometasone . . . . . . . . . . . . . 17ALDACTAZIDE . . . . . . . . . . . . 10ALDACTONE . . . . . . . . . . . . . . 10ALDARA . . . . . . . . . . . . . . . . . . 19ALDOMET . . . . . . . . . . . . . . . . 11ALECENSA . . . . . . . . . . . . . . . . 4alectinib . . . . . . . . . . . . . . . . . . . 4alendronate . . . . . . . . . . . . . . . 23

ALESSE . . . . . . . . . . . . . . . . . . 34alfuzosin ER . . . . . . . . . . . . . . . 46alginic acid/sodium

bicarbonate . . . . . . . . . . . . 25ALIGN . . . . . . . . . . . . . . . . . . . . 26alirocumab . . . . . . . . . . . . . . . . 11alitretinoin 1% gel . . . . . . . . . . . 6ALKERAN . . . . . . . . . . . . . . . . . 4allopurinol . . . . . . . . . . . . . . . . 33alogliptin . . . . . . . . . . . . . . . . . . 22alogliptin/metformin . . . . . . . . 22alogliptin/pioglitazone . . . . . . 22ALPHAGAN . . . . . . . . . . . . . . . 37ALPHAGAN P . . . . . . . . . . . . . 37alprazolam . . . . . . . . . . . . . . . . 38ALTACE . . . . . . . . . . . . . . . . . . . 8altretamine . . . . . . . . . . . . . . . . . 4alumina/magnesia . . . . . . . . . 25alumina/magnesia/

simethicone . . . . . . . . . . . . 25aluminum acetate . . . . . . .19, 20ALUNBRIG . . . . . . . . . . . . . . . . . 4amantadine . . . . . . . . . . . .15, 29AMARYL . . . . . . . . . . . . . . . . . 22AMBIEN . . . . . . . . . . . . . . . . . . 40ambrisentan . . . . . . . . . . . . . . . 11AMERGE . . . . . . . . . . . . . . . . . 14amiloride . . . . . . . . . . . . . . . . . 10amiloride/

hydrochlorothiazide . . . . . 10amiodarone tabs . . . . . . . . . . . . 8amitriptyline . . . . . . . . . . . .14, 39amitriptyline/perphenazine . . 39AMLACTIN . . . . . . . . . . . . . . . . 19amlodipine . . . . . . . . . . . . . . . . . 9ammonium lactate . . . . . . . . . 19AMNESTEEM . . . . . . . . . . . . . 16amoxapine . . . . . . . . . . . . . . . . 39amoxicillin . . . . . . . . . . . . . . . . 27amoxicillin/clavulanate . . . . . . 27

53



amphetamine/dextroamphetamine mixed salts . . . . . . . . . . . . . . . . . . 38

amphetamine/dextroamphetamine mixed salts extended-release . . . 38

ampicillin . . . . . . . . . . . . . . . . . 27anagrelide . . . . . . . . . . . . . . . . . 7anastrozole. . . . . . . . . . . . . . . . . 5ANTABUSE . . . . . . . . . . . . . . . 38ANTIVERT . . . . . . . . . . . . . . . . 24ANUSOL HC 2.5% . . . . . . . . . 19APHEDRID TAB . . . . . . . . . . . 45aprepitant . . . . . . . . . . . . . . . . . 24APRESOLINE . . . . . . . . . . . . . 11APRISO . . . . . . . . . . . . . . . . . . 25APTIVUS . . . . . . . . . . . . . . . . . 31ARALEN . . . . . . . . . . . . . . . . . . 31ARANESP . . . . . . . . . . . . . . . . . 7ARAVA . . . . . . . . . . . . . . . . . . . 32ARCAPTA NEOHALER . . . . . 45ARICEPT . . . . . . . . . . . . . . . . . 12ARIMIDEX . . . . . . . . . . . . . . . . . 5aripiprazole . . . . . . . . . . . . . . . 40aripiprazole ER injection . . . . 40aripiprazole injection . . . . . . . 40ARISTADA . . . . . . . . . . . . . . . . 40armodafinil . . . . . . . . . . . . . . . . 12ARNUITY ELLIPTA . . . . . . . . . 45AROMASIN . . . . . . . . . . . . . . . . 5ARTANE . . . . . . . . . . . . . . . . . . 15asfotase alfa . . . . . . . . . . . . . . . 23ASMANEX HFA . . . . . . . . . . . . 45aspirin . . . . . . . . . . . 7, 12, 13, 32aspirin/acetaminophen/

caffeine . . . . . . . . . . . . . . . 12ATARAX . . . . . . . . . . . . . . . . . . 20atazanavir . . . . . . . . . . . . . . . . . 30atenolol . . . . . . . . . . . . . . . . . . . . 9atenolol/chlorthalidone . . . . . . 9

ATIVAN . . . . . . . . . . . . . . . . . . . 38atorvastatin . . . . . . . . . . . . . . . 11atovaquone . . . . . . . . . . . . . . . 28ATRIPLA . . . . . . . . . . . . . . . . . . 30atropine . . . . . . . . . . . . . . .24, 37ATROVENT . . . . . . . . 21, 45, 46ATROVENT HFA . . . . . . . . . . . 45ATROVENT NASAL SPRAY . 21AUBAGIO . . . . . . . . . . . . . . . . . 14AUGMENTIN . . . . . . . . . . . . . . 27auranofin . . . . . . . . . . . . . . . . . 32AVITA . . . . . . . . . . . . . . . . . . . . 17axitinib . . . . . . . . . . . . . . . . . . . . 4AYGESTIN . . . . . . . . . . . . . . . . 35azathioprine . . . . . . . . . . . . . 6, 32azelastine . . . . . . . . . . . . . . . . . 35azithromycin . . . . . . . . . . . . . . 27aztreonam . . . . . . . . . . . . . . . . 49AZULFIDINE . . . . . . . 25, 26, 32AZULFIDINE EN-TABS . . .26, 32

Bb-complex . . . . . . . . . . . . . . . . 47B-COMPLEX VITAMIN TAB . . 47BACID . . . . . . . . . . . . . . . . . . . . 26bacitracin . . . . . . . . . . 17, 36, 37bacitracin/polymyxin/

neomycin/hc . . . . . . . . . . . 36baclofen . . . . . . . . . . . . . . . . . . 33BACTRIM . . . . . . . . . . . . . . . . . 28BACTRIM DS . . . . . . . . . . . . . . 28BACTROBAN . . . . . . . . . . . . . 17BALZIVA . . . . . . . . . . . . . . . . . . 34BANZEL . . . . . . . . . . . . . . . . . . 16BARACLUDE . . . . . . . . . . . . . . 28BASAGLAR . . . . . . . . . . . . . . . 22BAYER . . . . . . . . . . . . . . . . . 7, 32becaplermin gel . . . . . . . . . . . 19beclomethasone . . . . . . . . . . . 45bedaquiline . . . . . . . . . . . . . . . 31

BENADRYL . . . . . . . . . . . .20, 21benazepril . . . . . . . . . . . . . . . . . 8benazepril/

hydrochlorothiazide . . . . . . 8BENTYL . . . . . . . . . . . . . . . . . . 25BENZAC AC . . . . . . . . . . . . . . 16benznidazole . . . . . . . . . . . . . . 28benzocaine/antipyrine . . . . . . 20benzonatate . . . . . . . . . . . . . . . 41BENZOTIC . . . . . . . . . . . . . . . . 20benzoyl peroxide . . . . . . . . . . . 16benztropine . . . . . . . . . . . . . . . 15BERINERT . . . . . . . . . . . . . . . . 49BETA-VAL . . . . . . . . . . . . . . . . 17BETAGAN . . . . . . . . . . . . . . . . 36betamethasone augmented

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

augmented . . . . . . . . . . . . 18betamethasone dipropionate 18betamethasone val . . . . . . . . . 17BETAPACE . . . . . . . . . . . . . . . . 9BETAPACE AF . . . . . . . . . . . . . . 9betaxolol . . . . . . . . . . . . . . . . . . . 9bethanechol . . . . . . . . . . . . . . . 46BETHKIS . . . . . . . . . . . . . . . . . 49betrixaban . . . . . . . . . . . . . . . . . 7BEVYXXA . . . . . . . . . . . . . . . . . 7bexarotene caps and topical

gel . . . . . . . . . . . . . . . . . . . . . 6BIAXIN . . . . . . . . . . . . . . . . . . . 27BIAXIN XL . . . . . . . . . . . . . . . . 27bicalutamide . . . . . . . . . . . . . . . 5BICITRA . . . . . . . . . . . . . . . . . . 46BILTRICIDE . . . . . . . . . . . . . . . 26BIO-D DRO-MULSION . . . . . . 47BIO-D-MULSIO DRO FORTE 47BIOGAIA . . . . . . . . . . . . . . . . . . 26biperiden . . . . . . . . . . . . . . . . . 15bisoprolol . . . . . . . . . . . . . . . . . . 9

54


Index of Covered Drugsbisoprolol/

hydrochlorothiazide . . . . . . 9BLEPH-10 . . . . . . . . . . . . . . . . 37BOOSTRIX . . . . . . . . . . . . . . . . 51bosentan . . . . . . . . . . . . . . . . . 11BOSULIF . . . . . . . . . . . . . . . . . . 4bosutinib . . . . . . . . . . . . . . . . . . 4BREO ELLIPTA . . . . . . . . . . . . 45BRETHINE . . . . . . . . . . . . . . . . 46brigatinib . . . . . . . . . . . . . . . . . . 4brimonidine . . . . . . . . . . . . . . . 37BROMETANE DX . . . . . . . . . . 42BROMFED DM . . . . . . . . . . . . 42brompheniramine &

phenylephrine . . . . . . . . . . 41brompheniramine/

pseudoephedrine . . . .41, 42brompheniramine/

pseudoephedrine/dextromethorphan . . . . . . 42

budesonide . . . . . . . . . . . .25, 45bumetanide . . . . . . . . . . . . . . . 10BUMEX . . . . . . . . . . . . . . . . . . . 10BUPHENYL . . . . . . . . . . . . . . . 50buprenorphine . . . . . . . . . . . . 40buprenorphine/naloxone . . . . 40bupropion . . . . . . . . . . . . . . . . 39bupropion extended-release . 39BUSPAR . . . . . . . . . . . . . . . . . . 38buspirone . . . . . . . . . . . . . . . . . 38busulfan . . . . . . . . . . . . . . . . . . . 4butalbital/acetaminophen/

caffeine . . . . . . . . . . . . . . . 12butalbital/apap/caff/cod . . . . 13butalbital/asa/caff/cod . . . . . 13butalbital/aspirin/caffeine . . . 12butorphanol . . . . . . . . . . . . . . . 13

Cc1 esterase inhibitor, human . 49cabergoline . . . . . . . . . . . . . . . 23

CABOMETYX . . . . . . . . . . . . . . 4cabozantinib . . . . . . . . . . . . . . . 4CAFERGOT . . . . . . . . . . . . . . . 14calamine . . . . . . . . . . . . . . . . . . 19CALAN . . . . . . . . . . . . . . . .10, 14CALAN SR . . . . . . . . . . . . . . . . 10calcipotriene . . . . . . . . . . . . . . 18calcitonin-salmon . . . . . . . . . . 23calcitriol . . . . . . . . . . . . . . .18, 47calcitriol oral soln . . . . . . . . . . 47calcium . . . . . . . . 2, 9, 24, 47, 49calcium acetate . . . . . . . . . . . . 49calcium carb-vit D

w/ minerals . . . . . . . . . . . . 47CALQUENCE . . . . . . . . . . . . . . 4CALTRATE W/D . . . . . . . . . . . 47CAMPRAL . . . . . . . . . . . . . . . . 38canakinumab . . . . . . . . . . . . . 32capecitabine . . . . . . . . . . . . . . . 4CAPITROL . . . . . . . . . . . . . . . . 19CAPOTEN . . . . . . . . . . . . . . . . . 8CAPOZIDE . . . . . . . . . . . . . . . . . 8CAPRELSA . . . . . . . . . . . . . . . . 5capsaicin . . . . . . . . . . . . . . . . . 32captopril . . . . . . . . . . . . . . . . . . . 8captopril/hydrochlorothiazide . 8CARAFATE . . . . . . . . . . . . . . . . 25CARAFATE SUSPENSION . . 25CARBAGLU . . . . . . . . . . . . . . . 50carbamazepine . . . . . . . . . . . . 15carbamazepine extended-

release . . . . . . . . . . . . . . . . 15carbamide peroxide . . . . . . . . 20CARBATROL . . . . . . . . . . . . . . 15carbidopa/levodopa . . . . . . . . 15carbidopa/levodopa

extended-release . . . . . . . 15CARDEC DM DRO . . . . . . . . . 44CARDEC DM SYP . . . . . . . . . 43CARDEC DRO . . . . . . . . . . . . . 42

CARDEC SYP . . . . . . . . . . . . . 42CARDENE . . . . . . . . . . . . . . . . . 9CARDIZEM . . . . . . . . . . . . . . . 10CARDIZEM CD . . . . . . . . . . . . 10CARDIZEM SR . . . . . . . . . . . . 10CARDURA . . . . . . . . . . . . . . 8, 46carglumic acid . . . . . . . . . . . . . 50carteolol . . . . . . . . . . . . . . . . . . 36carvedilol . . . . . . . . . . . . . . . . . . 9casanthranol-docusate

sodium . . . . . . . . . . . . . . . . 24CASODEX . . . . . . . . . . . . . . . . . 5CATAFLAM . . . . . . . . . . . .12, 32CATAPRES . . . . . . . . . . . . . . . . . 8CAYSTON . . . . . . . . . . . . . . . . 49CECLOR . . . . . . . . . . . . . . . . . 27cefaclor . . . . . . . . . . . . . . . . . . . 27cefadroxil . . . . . . . . . . . . . . . . . 27cefdinir . . . . . . . . . . . . . . . . . . . 27cefprozil . . . . . . . . . . . . . . . . . . 27CEFTIN . . . . . . . . . . . . . . . . . . . 27cefuroxime axetil . . . . . . . . . . . 27CEFZIL . . . . . . . . . . . . . . . . . . . 27CELEBREX . . . . . . . . . . . . . . . 32celecoxib . . . . . . . . . . . . . . . . . 32CELEXA . . . . . . . . . . . . . . . . . . 39CELLCEPT . . . . . . . . . . . . . . . . . 6CENTRUM . . . . . . . . . . . . . . . . 47cephalexin . . . . . . . . . . . . . . . . 27ceritinib . . . . . . . . . . . . . . . . . . . . 4certolizumab pegol . . . . . . . . . 32cetirizine . . . . . . . . . . . . . . . . . . 20cetirizine chew tab . . . . . . . . . 20CHANTIX . . . . . . . . . . . . . . . . . 41CHEMET . . . . . . . . . . . . . . . . . 49CHILD IBUPRO SUS COLD . 44CHLOR-TRIMETON

ALLERGY . . . . . . . . . . . . . 20CHLOR-TRIMETON SYRUP . 20chloral hydrate . . . . . . . . . . . . . 40

55



chlorambucil . . . . . . . . . . . . . . . 4chlordiazepoxide. . . . . . . . . . . 38chlorhexidine gluconate. . . . . 21chloroquine phosphate . . . . . 31chlorothiazide . . . . . . . . . . . . . 10chloroxine . . . . . . . . . . . . . . . . 19chlorphen tan/carbetapentane

tan . . . . . . . . . . . . . . . . . . . . 42chlorphen tan/pyrilamine tan/PE

tan . . . . . . . . . . . . . . . . . . . . 42chlorpheniramine extended-

release . . . . . . . . . . . . . . . . 20chlorpheniramine maleate . . . 20chlorpheniramine tan/

phenylephrine tan. . . . . . . 42chlorpheniramine/

dextromethorphan . . . 42-44chlorpheniramine/

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

pseudoephedrine . . . . . . . 42chlorpromazine . . . . . . . . . . . . 41chlorpropamide. . . . . . . . . . . . 22chlorthalidone . . . . . . . . . . . 9, 10chlorzoxazone . . . . . . . . . . . . . 33CHOLBAM . . . . . . . . . . . . . . . . 23cholecalciferol . . . . . . . . . . . . . 47cholestyramine . . . . . . . . . . . . 10cholic acid . . . . . . . . . . . . . . . . 23choriogonadotropin alfa . . . . . 35chorionic gonadotropin . . . . . 35ciclopirox . . . . . . . . . . . . . . . . . 18cilostazol . . . . . . . . . . . . . . . . . . 7CILOXAN . . . . . . . . . . . . . . . . . 37CIMDUO . . . . . . . . . . . . . . . . . . 30cimetidine . . . . . . . . . . . . . . . . 25CIMZIA . . . . . . . . . . . . . . . . . . . 32cinacalcet . . . . . . . . . . . . . . . . . 23CIPRO . . . . . . . . . . . . . . . . . . . 27ciprofloxacin . . . . . . . . . . .27, 37citalopram . . . . . . . . . . . . . . . . 39

CLARAVIS . . . . . . . . . . . . . . . . 16clarithromycin . . . . . . . . . . . . . 27clarithromycin ER . . . . . . . . . . 27CLEAR EYES REDNESS

RELIEF . . . . . . . . . . . . . . . . 36clemastine . . . . . . . . . . . . . . . . 20CLEOCIN . . . . . . . . . . 16, 31, 35CLEOCIN T . . . . . . . . . . . . . . . 16CLIMARA . . . . . . . . . . . . . . . . . 35clindamycin . . . . . . . . 16, 31, 35CLINORIL . . . . . . . . . . . . . .13, 33clobazam . . . . . . . . . . . . . . . . . 15clobetasol propionate. . . . . . . 18clonazepam . . . . . . . . . . . .15, 38clonidine. . . . . . . . . . . . . . . . . . . 8clopidogrel . . . . . . . . . . . . . . . . . 7clorazepate . . . . . . . . . . . . . . . 38clotrimazole . . . . . . . . . . . .18, 28clotrimazole with

betamethasone . . . . . . . . . 18clozapine . . . . . . . . . . . . . . . . . 41CLOZARIL . . . . . . . . . . . . . . . . 41cobicistat . . . . . . . . . . . . . . . . . 31cobicistat/elvitegravir/

emtricitabine/tenofovir . . . 31cobimetinib . . . . . . . . . . . . . . . . 4codeine sulfate . . . . . . . . . . . . 13codeine/acetaminophen . . . . 13codeine/guaifenesin. . . . . . . . 42codeine/guaifenesin/

pseudoephedrine . . . . . . . 42codeine/promethazine. . . . . . 42codeine/promethazine/

phenylephrine . . . . . . . . . . 42CODIMAL DH . . . . . . . . . . . . . 44COGENTIN . . . . . . . . . . . . . . . 15COLACE . . . . . . . . . . . . . . . . . 24COLYTE . . . . . . . . . . . . . . . . . . 24COMBIVENT RESPIMAT . . . . 45COMBIVIR . . . . . . . . . . . . . . . . 30

COMETRIQ . . . . . . . . . . . . . . . . 4COMMITT OTC . . . . . . . . . . . . 41COMPAZINE . . . . . . . . . . . . . . 24COMPLERA . . . . . . . . . . . . . . 30COMPLETE NATALCARE PAK

DHA . . . . . . . . . . . . . . . . . . 47COMPOUND W . . . . . . . . . . . 18COMTAN . . . . . . . . . . . . . . . . . 15CONDYLOX SOL . . . . . . . . . . 19COPAXONE . . . . . . . . . . . . . . . 14CORDARONE . . . . . . . . . . . . . . 8COREG . . . . . . . . . . . . . . . . . . . 9CORICIDIN TAB CGH/CLD . . 42CORTEF . . . . . . . . . . . . . . . . . . 21cortisone acetate . . . . . . . . . . 21CORTISPORIN . . . . . . . . .20, 36CORTISPORIN OTIC . . . . . . . 20CORTIZONE . . . . . . . . . . . . . . 17CORTIZONE-10 INTENSIVE

HEALING . . . . . . . . . . . . . . 17COSENTYX . . . . . . . . . . . . . . . 32COSOPT . . . . . . . . . . . . . . . . . 36COTELLIC . . . . . . . . . . . . . . . . . 4COUMADIN . . . . . . . . . . . . . . . . 7COZAAR . . . . . . . . . . . . . . . . . . 8CREON . . . . . . . . . . . . . . . . . . . 26CREON 3000 UNIT . . . . . . . . 26CRIXIVAN . . . . . . . . . . . . . . . . . 30crizotinib . . . . . . . . . . . . . . . . . . . 4crofelemer . . . . . . . . . . . . . . . . 24CROLOM . . . . . . . . . . . . . . . . . 35cromolyn . . . . . . . . . . 21, 35, 45cromolyn sodium . . . . . . .21, 35crotamiton . . . . . . . . . . . . . . . . 19CULTURELLE . . . . . . . . . . . . . 26CUTIVATE . . . . . . . . . . . . . . . . 17cyanocobalamin . . . . . . . . . . . 47CYCLESSA . . . . . . . . . . . . . . . 34cyclobenzaprine . . . . . . . . . . . 33CYCLOGYL . . . . . . . . . . . . . . . 37

56


Index of Covered Drugscyclopentolate . . . . . . . . . . . . . 37cyclophosphamide . . . . . . . . . . 4cycloserine . . . . . . . . . . . . . . . . 28cyclosporine . . . . . . . . . . . . . . . 6cyclosporine, modified . . . . . . . 6CYMBALTA . . . . . . . . . . . . . . . 39cyproheptadine . . . . . . . . . . . . 20CYSTAGON . . . . . . . . . . . . . . . . 6CYSTARAN . . . . . . . . . . . . . . . 37cysteamine 0.44% . . . . . . . . . 37cysteamine bitartrate . . . . . . . . 6CYTOMEL . . . . . . . . . . . . . . . . 23CYTOTEC . . . . . . . . . . . . . . . . 26CYTOVENE . . . . . . . . . . . . . . . 28CYTOXAN . . . . . . . . . . . . . . . . . 4

DD3-50 CAP . . . . . . . . . . . . . . . . 47D.H.E. 45 . . . . . . . . . . . . . . . . . 14dabrafenib . . . . . . . . . . . . . . . . . 4daclizumab . . . . . . . . . . . . . . . 14DALMANE . . . . . . . . . . . . . . . . 40danazol . . . . . . . . . . . . . . . . . . . 34DANOCRINE . . . . . . . . . . . . . . 34DANTRIUM . . . . . . . . . . . . . . . 33dantrolene . . . . . . . . . . . . . . . . 33dapsone . . . . . . . . . . . . . . . . . . 31DARAPRIM . . . . . . . . . . . . . . . 31darbepoetin alfa . . . . . . . . . . . . 7darunavir . . . . . . . . . . . . . .30, 31darunavir/cobicistat . . . . . . . . 31dasabuvir/ombitasvir/

paritaprevir/ritonavir . . . . . 28dasatinib . . . . . . . . . . . . . . . . . . . 4DAYPRO . . . . . . . . . . . . . . .13, 33DDAVP . . . . . . . . . . . . . . . . . . . 23DEBROX . . . . . . . . . . . . . . . . . 20DECADRON . . . . . . . . . . . . . . 21deferasirox . . . . . . . . . . . . . . . . . 7

DELATESTRYL . . . . . . . . . . . . 21delavirdine . . . . . . . . . . . . . . . . 29DELSYM . . . . . . . . . . . . . . . . . . 43DELTASONE . . . . . . . . . . . . . . 21DEMADEX . . . . . . . . . . . . . . . . 10DEMEROL . . . . . . . . . . . . . . . . 13DEPAKENE . . . . . . . . . . . . . . . 16DEPAKOTE . . . . . . . . 14, 15, 39DEPAKOTE SPRINKLE . .14, 15DEPEN TITRATABLE . . . . . . . 32DEPO-PROVERA . . . . . . . . . . 33DEPO-TESTOSTERONE . . . . 21DERMA-SMOOTHE OIL/FS . 17DERMAPHOR OINTMENT . . 19DERMATOP . . . . . . . . . . . . . . . 17DESCOVY . . . . . . . . . . . . . . . . 30DESENEX . . . . . . . . . . . . . . . . 18desipramine . . . . . . . . . . . . . . . 39desmopressin . . . . . . . . . . . . . 23desogestrel/EE . . . . . . . . .33, 34DESYREL . . . . . . . . . . . . . . . . . 40DETROL . . . . . . . . . . . . . . . . . . 46dexamethasone . . . . . . . .21, 36dexamethasone sodium

phosphate . . . . . . . . . . . . . 36DEXASOL . . . . . . . . . . . . . . . . 36dextromethorphan hbr . . . . . . 43dextromethorphan polistirex

extended-release . . . . . . . 43dextromethorphan-

guaifenesin 42, 43dextromethorphan/

brompheniramine/pseudoephedrine . . . . . . . 42

dextromethorphan/ guaifenesin . . . . . . . . .43, 44

dextromethorphan/promethazine . . . . . . . . . . 43

DIABINESE . . . . . . . . . . . . . . . 22DIAMOX SEQUELS . . . . . . . . 37diazepam . . . . . . . . . . . . . .33, 38

diclofenac 1% gel . . . . . . . . . . 32diclofenac potassium . . . .12, 32diclofenac sodium delayed-

release . . . . . . . . . . . . .12, 32diclofenac sodium extended-

release . . . . . . . . . . . . .12, 32dicloxacillin . . . . . . . . . . . . . . . 27dicyclomine . . . . . . . . . . . . . . . 25didanosine . . . . . . . . . . . . . . . . 30didanosine delayed-release . . 30DIDRONEL. . . . . . . . . . . . . . . . 23DIFFERIN OTC GEL 0.1% . . . 16DIFLUCAN . . . . . . . . . . . . .28, 35DIGESTIVE PROBIOTIC . . . . 26digoxin . . . . . . . . . . . . . . . . . . . . 8DIHYDRO-PE SYP . . . . . . . . . 44dihydroergotamine . . . . . . . . . 14DILACOR XR . . . . . . . . . . . . . . 10DILANTIN . . . . . . . . . . . . . . . . . 16DILANTIN INFATABS . . . . . . . 16DILAUDID . . . . . . . . . . . . . . . . 13diltiazem . . . . . . . . . . . . . . . . . . 10diltiazem extended-release . . 10diltiazem sustained-release . . 10DIMEATAPP DRO

DECONGES . . . . . . . . . . . 21DIMETAPP CLD ELX/

ALLERGY . . . . . . . . . . . . . 41DIMETAPP DRO DCON/

CGH . . . . . . . . . . . . . . . . . . 44DIMETAPP SYP CGH/CLD . . 42dimethyl fumarate . . . . . . . . . . 14DIP/TET PED INJ . . . . . . . . . . 50DIPENTUM . . . . . . . . . . . . . . . 25diphenhydramine . . . 20, 21, 40diphenoxylate/atropine . . . . . 24diphtheria-tetanus tox

adsorbed (dt) im . . . . . . . . 50DIPROLENE . . . . . . . . . . .17, 18DIPROLENE AF . . . . . . . . . . . 17

57



dipyridamole . . . . . . . . . . . . . . . 7DISALCID . . . . . . . . . . . . . . . . . 33disopyramide . . . . . . . . . . . . . 8, 9disopyramide

extended-release . . . . . . . . 9disulfiram . . . . . . . . . . . . . . . . . 38DITROPAN . . . . . . . . . . . . . . . . 46DITROPAN XL . . . . . . . . . . . . . 46DIURIL . . . . . . . . . . . . . . . . . . . 10DIURIL ORAL SUSPENSION 10divalproex sodium cap

sprinkle . . . . . . . . 14, 15, 39divalproex sodium delayed-

release . . . . . . . . . 14, 15, 39docosanol . . . . . . . . . . . . . . . . 29docusate calcium plus . . . . . . 24docusate potasssium . . . . . . . 24docusate sodium . . . . . . . . . . 24dofetilide. . . . . . . . . . . . . . . . . . . 9dolutegravir . . . . . . . . . . . .29, 31dolutegravir/rilpivirine . . . . . . . 31DOMEBORO OTIC . . . . . . . . . 20donepezil . . . . . . . . . . . . . . . . . 12dornase alfa . . . . . . . . . . . . . . . 49dorzolamide . . . . . . . . . . . . . . . 36dorzolamide/timolol maleate 36DOSTINEX . . . . . . . . . . . . . . . . 23DOVONEX . . . . . . . . . . . . . . . . 18doxazosin . . . . . . . . . . . . . . . 8, 46doxepin . . . . . . . . . . . . . . . . . . 39doxycycline monohydrate . . . 28doxylamine succinate . . . . . . . 40DRISDOL . . . . . . . . . . . . . . . . . 47DROXIA . . . . . . . . . . . . . . . . . . . 6dulaglutide . . . . . . . . . . . . . . . . 22duloxetine . . . . . . . . . . . . . . . . 39DUOFILM . . . . . . . . . . . . . . . . . 18DUONEB . . . . . . . . . . . . . . . . . 46DURAGESIC . . . . . . . . . . . . . . 13DURATUSS DM ELX . . . . . . . 42

DURICEF . . . . . . . . . . . . . . . . . 27DYAZIDE . . . . . . . . . . . . . . . . . 10

EE-OINTMENT . . . . . . . . . . . . . 19E.E.S. . . . . . . . . . . . . . . . . . . . . 27ECOTRIN . . . . . . . . . . . . . . . 7, 32EDGE OB CHW . . . . . . . . . . . 48EDURANT . . . . . . . . . . . . . . . . 29efavirenz . . . . . . . . . . . . . . .29, 30efavirenz/emtricitabine/

tenofovir . . . . . . . . . . . . . . . 30efavirenz/lamivudine/tenofovir

disoproxil fumarate . . . . . . 30EFFEXOR . . . . . . . . . . . . . . . . . 39EFFEXOR XR . . . . . . . . . . . . . . 39EFUDEX . . . . . . . . . . . . . . . . . . 19ELAVIL . . . . . . . . . . . . . . . .14, 39elbasvir/grazoprevir . . . . . . . . 28ELDEPRYL . . . . . . . . . . . . . . . . 15electrolyte . . . . . . . . . . . . . . . . . 47ELIMITE . . . . . . . . . . . . . . . . . . 19ELMIRON . . . . . . . . . . . . . . . . . 46ELOCON . . . . . . . . . . . . . . . . . 17eltrombopag . . . . . . . . . . . . . . 49elvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate . . . 31

EMCYT . . . . . . . . . . . . . . . . . . . . 4EMEND . . . . . . . . . . . . . . . . . . 24emicizumab-kxwh . . . . . . . . . . . 7EMLA . . . . . . . . . . . . . . . . . . . . 19emollients . . . . . . . . . . . . . . . . . 19emtricitabine . . . . . . . . . . .30, 31emtricitabine/rilpivirine/

tenofovir . . . . . . . . . . . . . . . 30emtricitabine/tenofovir

alafenamide . . . . . . . . .30, 31emtricitabine/tenofovir

disoproxil . . . . . . . . . . . . . . 30EMTRIVA . . . . . . . . . . . . . . . . . 30

enalapril . . . . . . . . . . . . . . . . . . . 8enalapril/hydrochlorothiazide . 8ENBREL . . . . . . . . . . . . . . . . . . 32enfuvirtide . . . . . . . . . . . . . . . . 31ENGERIX-B . . . . . . . . . . . . . . . 50enoxaparin . . . . . . . . . . . . . . . . . 7entacapone . . . . . . . . . . . . . . . 15entecavir . . . . . . . . . . . . . . . . . . 28ENTERIC COATED-

NAPROSYN . . . . . . . . .13, 33ENTOCORT EC . . . . . . . . . . . . 25ENTRESTO . . . . . . . . . . . . . . . . 8ENULOSE . . . . . . . . . . . . . . . . 24EPCLUSA . . . . . . . . . . . . . . . . . 29epinephrine . . . . . . . . . . . .37, 49EPIPEN . . . . . . . . . . . . . . . . . . . 49EPIPEN JR. . . . . . . . . . . . . . . . 49EPIVIR . . . . . . . . . . . . . . . .29, 30EPIVIR HBV . . . . . . . . . . . . . . . 29epoetin alfa . . . . . . . . . . . . . . . . 7EPOGEN . . . . . . . . . . . . . . . . . . 7EPZICOM . . . . . . . . . . . . . . . . . 29ergocalciferol (D2) . . . . . . . . . 47ergotamine tartrate/caffeine . 14ergotamine/caffeine . . . . . . . . 14ERIVEDGE . . . . . . . . . . . . . . . . . 7erlotinib . . . . . . . . . . . . . . . . . . . 4ertugliflozin . . . . . . . . . . . . . . . 22ertugliflozin/metformin . . . . . . 22ERYC . . . . . . . . . . . . . . . . . . . . 27ERYGEL . . . . . . . . . . . . . . . . . . 16ERYTHROCIN . . . . . . . . . . . . . 27erythromycin . . . . . . . 16, 27, 37erythromycin delayed-release 27erythromycin ethylsuccinate . 27erythromycin stearate . . . . . . . 27erythromycin/sulfisoxazole . . 27escitalopram . . . . . . . . . . . . . . 39ESKALITH CR . . . . . . . . . . . . . 39ESTRACE . . . . . . . . . . . . . . . . . 35

58


Index of Covered Drugsestradiol . . . . . . . . . . . . . . . . . . 35estramustine phosphate

sodium . . . . . . . . . . . . . . . . . 4estrogens, conjugated . . . . . . 35estrogens, conjugated/

medroxyprogesterone . . . 35estropipate . . . . . . . . . . . . . . . . 35ESTROSTEP FE . . . . . . . . . . . 34etanercept . . . . . . . . . . . . . . . . 32ethambutol . . . . . . . . . . . . . . . . 27ethosuximide . . . . . . . . . . . . . . 15ethynodiol diacetate/EE . . . . . 34etidronate . . . . . . . . . . . . . . . . . 23etodolac . . . . . . . . . . . . . . .12, 32etonogestrel/EE . . . . . . . . . . . 33etoposide . . . . . . . . . . . . . . . . . . 6etravirine . . . . . . . . . . . . . . . . . . 29EULEXIN . . . . . . . . . . . . . . . . . . 5EURAX . . . . . . . . . . . . . . . . . . . 19everolimus . . . . . . . . . . . . . . . 4, 6EVISTA . . . . . . . . . . . . . . . . . . . 23EXCEDRIN MIGRAINE . . . . . . 12EXELON PATCH . . . . . . . . . . . 12EXELON TABS . . . . . . . . . . . . 12exemestane . . . . . . . . . . . . . . . . 5EXJADE . . . . . . . . . . . . . . . . . . . 7ezetimibe . . . . . . . . . . . . . . . . . 11

Ffamotidine . . . . . . . . . . . . . . . . 25FARESTON . . . . . . . . . . . . . . . . 5FARYDAK . . . . . . . . . . . . . . . . . . 4felbamate . . . . . . . . . . . . . . . . . 15felbamate oral susp . . . . . . . . 15FELBATOL . . . . . . . . . . . . . . . . 15FELDENE . . . . . . . . . . . . . .13, 33felodipine extended-release . . 9FEMARA . . . . . . . . . . . . . . . . . . 5fenofibrate . . . . . . . . . . . . . . . . 10fentanyl transdermal . . . . . . . . 13

FEOSOL . . . . . . . . . . . . . . . . . . 47ferrous sulfate . . . . . . . . . . . . . 47filgrastim . . . . . . . . . . . . . . . . . . . 7finasteride . . . . . . . . . . . . . . . . 46fingolimod . . . . . . . . . . . . . . . . 14FIORICET . . . . . . . . . . . . . .12, 13FIORICET W/CODEINE . . . . . 13FIORINAL . . . . . . . . . . . . . .12, 13FIORINAL W/CODEINE . . . . . 13FIRAZYR . . . . . . . . . . . . . . . . . 49FLAGYL . . . . . . . . . . . . . . .31, 35flecainide . . . . . . . . . . . . . . . . . . 9FLEXERIL . . . . . . . . . . . . . . . . . 33FLOMAX. . . . . . . . . . . . . . . . . . 46FLONASE . . . . . . . . . . . . . . . . . 20FLORAJEN . . . . . . . . . . . . . . . 26FLORANEX . . . . . . . . . . . . . . . 26FLORASTOR . . . . . . . . . . . . . . 26FLORINEF . . . . . . . . . . . . . . . . 21FLOXIN . . . . . . . . . . . . . . . .20, 27FLOXIN OTIC . . . . . . . . . . . . . . 20FLUARIX QUAD . . . . . . . . . . . 50FLUBLOK . . . . . . . . . . . . . . . . . 50FLUCELVAX . . . . . . . . . . . . . . . 50fluconazole . . . . . . . . . . . .28, 35fludrocortisone . . . . . . . . . . . . 21FLULAVAL QUAD . . . . . . . . . . 50FLUMADINE . . . . . . . . . . . . . . 29fluocinolone acetonide . . . . . . 17fluocinonide . . . . . . . . . . . . . . . 18fluocinonide emulsified base 18fluoride . . . . . . . . . . . . . . . .47, 48fluorometholone . . . . . . . . . . . 36fluorouracil . . . . . . . . . . . . . . . . 19fluoxetine . . . . . . . . . . . . . . . . . 39fluphenazine . . . . . . . . . . . . . . 41fluphenazine decanoate . . . . 41flurazepam . . . . . . . . . . . . . . . . 40flurbiprofen . . . . . . . . . . . . . . . 36

flutamide . . . . . . . . . . . . . . . . . . 5fluticasone . . . . . . . . . 17, 20, 45fluticasone furoate . . . . . . . . . 45fluticasone propionate . . . . . . 17fluticasone/salmeterol . . . . . . 45fluticasone/vilanterol . . . . . . . 45FLUVIRIN . . . . . . . . . . . . . . . . . 51fluvoxamine . . . . . . . . . . . . . . . 38FLUZONE HD PF . . . . . . . . . . 50FLUZONE QUAD. . . . . . . . . . . 50FML FORTE . . . . . . . . . . . . . . . 36FML LIQUIFILM . . . . . . . . . . . . 36folic acid . . . . . . . . . . . . . . .47, 48FOLTABS PAK PLUS DHA RE

OB + DHA PAK . . . . . . . . . 48FOLTABS PRENATAL . . . . . . . 48FORTICAL . . . . . . . . . . . . . . . . 23FOSAMAX . . . . . . . . . . . . . . . . 23fosamprenavir . . . . . . . . . . . . . 30fosinopril. . . . . . . . . . . . . . . . . . . 8fosinopril/hydrochlorothiazide 8FURADANTIN SUSP

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

Ggabapentin . . . . . . . . . . . . . . . . 15GABITRIL . . . . . . . . . . . . . . . . . 16galantamine . . . . . . . . . . . . . . . 12ganciclovir . . . . . . . . . . . . . . . . 28GARDASIL . . . . . . . . . . . . . . . . 50GARDASIL 9 . . . . . . . . . . . . . . 50GATTEX . . . . . . . . . . . . . . . . . . 26gefitinib . . . . . . . . . . . . . . . . . . . . 4GEL-KAM . . . . . . . . . . . . . . . . . 47gemfibrozil . . . . . . . . . . . . . . . . 10GENTAK . . . . . . . . . . . . . . .17, 37gentamicin . . . . . . . . . . . . .17, 37GENTEX ADE 28-1 MG . . . . . 48

59



GENVOYA . . . . . . . . . . . . . . . . 31GEODON . . . . . . . . . . . . . . . . . 41GG/CODEINE . . . . . . . . . . . . . 42GG/DM CR . . . . . . . . . . . . . . . 43GILENYA . . . . . . . . . . . . . . . . . 14GILOTRIF . . . . . . . . . . . . . . . . . . 4glatiramer acetate . . . . . . . . . . 14GLATOPA . . . . . . . . . . . . . . . . . 14GLEEVEC . . . . . . . . . . . . . . . . . 5GLEOSTINE . . . . . . . . . . . . . . . . 4glimepiride . . . . . . . . . . . . . . . . 22glipizide . . . . . . . . . . . . . . . . . . 23glipizide extended-release . . . 23GLUCAGON . . . . . . . . . . . . . . 21glucagon, human

recombinant . . . . . . . . . . . 21GLUCOPHAGE . . . . . . . . . . . . 23GLUCOPHAGE ER . . . . . . . . . 23GLUCOTROL . . . . . . . . . . . . . 23GLUCOTROL XL . . . . . . . . . . . 23GLUCOVANCE . . . . . . . . . . . . 23glyburide . . . . . . . . . . . . . . . . . 23glyburide, micronized . . . . . . . 23glycerin . . . . . . . . . . . . 19, 24, 36GLYCERIN SUPPOSITORY . . 24GLYCERIN TOPICAL . . . . . . . 19glycerol phenylbutyrate . . . . . 50glycopyrrolate . . . . . . . . . . . . . 25GLYNASE . . . . . . . . . . . . . . . . . 23GRIFULVIN V . . . . . . . . . . . . . . 28GRIS-PEG . . . . . . . . . . . . . . . . 28griseofulvin microsize . . . . . . . 28griseofulvin ultramicrosize . . . 28guaifenesin . . . . . . . . . . . . 42-44guaifenesin extended-release 43guaifenesin/

pseudoephedrine . . . .42, 43guaifenesin/pseudoephedrine

extended-release . . . . . . . 43

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

guanabenz . . . . . . . . . . . . . . . . 11guanfacine . . . . . . . . . . . . . . 8, 38guanfacine ER . . . . . . . . . . . . . 38GUIATUSS AC . . . . . . . . . . . . . 42GUIATUSS DAC . . . . . . . . . . . 42

HHAEGARDA . . . . . . . . . . . . . . . 49HALCION . . . . . . . . . . . . . . . . . 40HALDOL . . . . . . . . . . . . . . . . . . 41HALDOL DECANOATE . . . . . 41halobetasol . . . . . . . . . . . . . . . 18haloperidol . . . . . . . . . . . . . . . . 41haloperidol decanoate . . . . . . 41HARVONI . . . . . . . . . . . . . . . . . 29HAVRIX . . . . . . . . . . . . . . . . . . . 50HECORIA . . . . . . . . . . . . . . . . . . 6HEMLIBRA . . . . . . . . . . . . . . . . 7heparin . . . . . . . . . . . . . . . . . . . . 7hepatitis a vaccine susp . . . . . 50hepatitis b vaccine

(recombinant) . . . . . . . . . . 50hepatitis b vaccine recombinant

adjuvanted . . . . . . . . . . . . . 50HEPLISAV-B . . . . . . . . . . . . . . 50HEXALEN . . . . . . . . . . . . . . . . . 4HIPREX . . . . . . . . . . . . . . . . . . 46HIVID . . . . . . . . . . . . . . . . . . . . 30homatropine . . . . . . . . . . .37, 43HUMALOG MIX 50/50. . . . . . 22HUMALOG MIX 75/25. . . . . . 22human papillomavirus (hpv)

9-valent recomb vac . . . . . 50human papillomavirus (hpv)

quadrivalent recombinant vac . . . . . . . . . . . . . . . . . . . 50

HUMATIN . . . . . . . . . . . . . . . . . 31HUMIRA . . . . . . . . . . . . . . . . . . 32

HUMULIN 70/30 . . . . . . . . . . 22HUMULIN N . . . . . . . . . . . . . . . 22HUMULIN R . . . . . . . . . . . . . . . 22HYCAMTIN . . . . . . . . . . . . . . . . 7HYCODAN . . . . . . . . . . . . . . . . 43hydralazine. . . . . . . . . . . . . . . . 11HYDREA . . . . . . . . . . . . . . . . . . 6hydrochlorothiazide . . . . . . 8-10hydrocodone ER . . . . . . . . . . . 13hydrocodone/

acetaminophen . . . . . . . . . 13hydrocodone/homatropine . . 43HYDROCODONE/TAB

HOMATROP . . . . . . . . . . . 43hydrocortisone . . 17, 19-21, 36hydrocortisone butyrate . . . . . 17hydrocortisone valerate . . . . . 17hydrocortisone/aloe . . . . . . . . 17HYDROMET SYP . . . . . . . . . . 43hydromorphone . . . . . . . . . . . 13hydroxychloroquine . . . . .31, 32hydroxyurea . . . . . . . . . . . . . . . . 6hydroxyzine HCL . . . . . . . . . . . 20hydroxyzine pamoate . . . . . . . 20hyoscyamine sulfate . . . . . . . . 25hyoscyamine sulfate

extended-release . . . . . . . 25HYPERSAL . . . . . . . . . . . . . . . 49HYPERTET S/D . . . . . . . . . . . 51HYTONE . . . . . . . . . . . . . . . . . 17HYTRIN . . . . . . . . . . . . . . . . 8, 46HYZAAR . . . . . . . . . . . . . . . . . . 8

IIBRANCE . . . . . . . . . . . . . . . . . . 5ibrutinib . . . . . . . . . . . . . . . . . . . 4IBUOROFEN TAB

COLD/SIN . . . . . . . . . . . . . 44ibuprofen . . . . . . . . . . . . . .13, 32icatibant . . . . . . . . . . . . . . . . . . 49

60


Index of Covered DrugsICLUSIG . . . . . . . . . . . . . . . . . . . 5idelalisib . . . . . . . . . . . . . . . . . . . 5ILARIS . . . . . . . . . . . . . . . . . . . 32imatinib mesylate . . . . . . . . . . . 5IMBRUVICA . . . . . . . . . . . . . . . . 4IMDUR . . . . . . . . . . . . . . . . . . . 11imipramine HCL . . . . . . . . . . . 39imiquimod 5% cream . . . . . . . 19IMITREX . . . . . . . . . . . . . . . . . . 14IMITREX 4 MG AND

6 MG INJ . . . . . . . . . . . . . . 14IMODIUM A-D . . . . . . . . . . . . . 24IMPAVIDO . . . . . . . . . . . . . . . . 28IMURAN . . . . . . . . . . . . . . . . 6, 32INCRELEX . . . . . . . . . . . . . . . . 23INCRUSE ELLIPTA . . . . . . . . . 45indacaterol . . . . . . . . . . . . . . . . 45indapamide . . . . . . . . . . . . . . . 10INDERAL . . . . . . . . . . . . . . . 9, 14INDERAL LA . . . . . . . . . . . . . . . 9INDERIDE . . . . . . . . . . . . . . . . . 9indinavir . . . . . . . . . . . . . . . . . . 30INDOCIN . . . . . . . . . . . . . .13, 32indomethacin . . . . . . . . . .13, 32INFLAMASE FORTE . . . . . . . . 36influenza virus vaccine

recombinant hemagglutinin (ha) . . . . . . . . . . . . . . . . . . . 50

influenza virus vaccine split . . 50influenza virus vaccine split

high-dose pf . . . . . . . . . . . 50influenza virus vaccine split pf 50influenza virus vaccine split

quadrivalent . . . . . . . . . . . . 50influenza virus vaccine tiss-cult

subunit . . . . . . . . . . . . . . . . 50influenza virus vaccine types

a&b surface antigen . . . . . 51INGREZZA . . . . . . . . . . . . . . . . 16INLYTA . . . . . . . . . . . . . . . . . . . . 4

insulin aspart protamine 70%/insulin aspart 30% . . . . . . 22

insulin glargine . . . . . . . . . . . . 22insulin glargine 300 units/ml 22insulin glargine/lixisenatide . 21insulin human . . . . . . . . . . . . . 22insulin isophane . . . . . . . . . . . 22insulin isophane human . . . . . 22insulin isophane human 70%/

regular 30% . . . . . . . . . . . . 22insulin isophane/regular . . . . 22insulin lisopro pro/lispro . . . . 22insulin lisopro prot/lispro . . . . 22insulin lispro . . . . . . . . . . . . . . . 22insulin regular . . . . . . . . . . . . . 22insulin syringes . . . . . . . . . . . . 50INTAL . . . . . . . . . . . . . . . . . . . . 45INTELENCE . . . . . . . . . . . . . . . 29interferon alfa-2b . . . . . . . . . 6, 29interferon gamma-1b . . . . . . . . 6INTRON A . . . . . . . . . . . . . . 6, 29INTUNIV . . . . . . . . . . . . . . . . . . 38INVEGA SUSTENNA . . . . . . . 41INVEGA TRINZA . . . . . . . . . . . 41INVIRASE . . . . . . . . . . . . . . . . . 31ipratropium . . . . . . . . 21, 45, 46ipratropium HFA . . . . . . . . . . . 45ipratropium nasal . . . . . . . . . . 21ipratropium/albuterol . . . .45, 46IRESSA . . . . . . . . . . . . . . . . . . . . 4ISENTRESS . . . . . . . . . . . . . . . 29ISENTRESS CHEWABLE . . . 29ISENTRESS HD . . . . . . . . . . . 29ISENTRESS SUSP . . . . . . . . . 29ISMO . . . . . . . . . . . . . . . . . . . . . 11isoniazid . . . . . . . . . . . . . . . . . . 27ISOPTO ATROPINE . . . . . . . . 37ISOPTO CARPINE . . . . . . . . . 37ISOPTO HOMATROPINE. . . . 37ISORDIL . . . . . . . . . . . . . . . . . . 11

isosorbide dinitrate . . . . . . . . . 11ISOSORBIDE DINITRATE ER 11isosorbide dinitrate extended-

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

extended-release . . . . . . . 11isotretinoin . . . . . . . . . . . . . . . . 16itraconazole . . . . . . . . . . . . . . . 28ivacaftor . . . . . . . . . . . . . . . . . . 49ivermectin . . . . . . . . . . . . . . . . 26ixazomib . . . . . . . . . . . . . . . . . . . 5

JJADENU . . . . . . . . . . . . . . . . . . . 7JAKAFI . . . . . . . . . . . . . . . . . . . . 5JULUCA . . . . . . . . . . . . . . . . . . 31

KK-DUR 10 . . . . . . . . . . . . . . . . . 49K-DUR 20 . . . . . . . . . . . . . . . . . 49K-LOR . . . . . . . . . . . . . . . . . . . . 49KALETRA . . . . . . . . . . . . . . . . 30KALYDECO . . . . . . . . . . . . . . . 49KAYEXALATE . . . . . . . . . . . . . 11KAZANO . . . . . . . . . . . . . . . . . 22KEFLEX . . . . . . . . . . . . . . . . . . 27KENALOG . . . . . . . . . 17, 18, 21KENALOG IN ORABASE . . . . 21KEPPRA . . . . . . . . . . . . . . . . . . 15KERLONE . . . . . . . . . . . . . . . . . 9ketoconazole . . . . . . . 18, 19, 28ketoprofen . . . . . . . . . . . . .13, 32ketorolac . . . . . . . . . . . . . .13, 36ketorolac tromethamine . . . . . 13ketotifen . . . . . . . . . . . . . . . . . . 36KEVZARA . . . . . . . . . . . . . . . . 32KLONOPIN . . . . . . . . . . . .15, 38KLOR-CON 10 . . . . . . . . . . . . 49KLOR-CON 8 . . . . . . . . . . . . . 49

61



KORLYM . . . . . . . . . . . . . . . . . 23KUVAN . . . . . . . . . . . . . . . .23, 24KUVAN POWDER FOR

SOLUTION . . . . . . . . . . . . 24

Llabetalol . . . . . . . . . . . . . . . . . . . 9LAC-HYDRIN . . . . . . . . . . . . . . 19LACTINEX . . . . . . . . . . . . . . . . 26LACTINOL . . . . . . . . . . . . . . . . 19lactulose . . . . . . . . . . . . . . . . . . 24LAMICTAL . . . . . . . . . . . . . . . . 15LAMICTAL CD CHEW TAB . . 15LAMICTAL STARTER KIT . . . 15LAMISIL . . . . . . . . . . . . . . .18, 28LAMISIL AT . . . . . . . . . . . . . . . 18lamivudine . . . . . . . . . . . . . 29-31lamivudine/tenofovir disoproxil

fumarate . . . . . . . . . . . . . . . 30lamivudine/zidovudine . . . . . . 30lamotrigine . . . . . . . . . . . . . . . . 15lamotrigine chew dispersable

tab . . . . . . . . . . . . . . . . . . . . 15lamotrigine starter kit . . . . . . . 15lancets . . . . . . . . . . . . . . . . . . . 50LANOXIN . . . . . . . . . . . . . . . . . . 8lansoprazole . . . . . . . . . . . . . . 25lansoprazole delayed-release 25lapatinib ditosylate . . . . . . . . . . 5LARIAM . . . . . . . . . . . . . . . . . . 31LASIX . . . . . . . . . . . . . . . . . . . . 10latanoprost . . . . . . . . . . . . . . . . 37ledipasvir/sofosbuvir . . . . . . . 29leflunomide . . . . . . . . . . . . . . . 32lenalidomide . . . . . . . . . . . . . . . 6lenvatinib . . . . . . . . . . . . . . . . . . 5LENVIMA . . . . . . . . . . . . . . . . . . 5LETAIRIS . . . . . . . . . . . . . . . . . 11letrozole . . . . . . . . . . . . . . . . . . . 5leucovorin . . . . . . . . . . . . . . . . . 5

LEUKERAN . . . . . . . . . . . . . . . . 4LEUKINE . . . . . . . . . . . . . . . . . . 7leuprolide . . . . . . . . . . . . . . . . 5, 6LEUPROLIDE ACETATE . . . . . 6levalbuterol HCl . . . . . . . . . . . . 46LEVAQUIN . . . . . . . . . . . . . . . . 27levetiracetam . . . . . . . . . . . . . . 15levobunolol . . . . . . . . . . . . . . . 36levocetirizine . . . . . . . . . . . . . . 20levofloxacin . . . . . . . . . . . . . . . 27levonorgestrel . . . . . . . . . .33, 34levonorgestrel/EE . . . . . . .33, 34levothyroxine . . . . . . . . . . . . . . 23LEVOXYL . . . . . . . . . . . . . . . . . 23LEVSIN . . . . . . . . . . . . . . . . . . . 25LEVSINEX . . . . . . . . . . . . . . . . 25LEXAPRO . . . . . . . . . . . . . . . . 39LEXIVA . . . . . . . . . . . . . . . . . . . 30LIBRIUM . . . . . . . . . . . . . . . . . . 38LIDAMANTEL . . . . . . . . . . . . . 19LIDEX . . . . . . . . . . . . . . . . . . . . 18LIDEX E . . . . . . . . . . . . . . . . . . 18lidocaine . . . . . . . . . . . . . . .19, 21lidocaine patch . . . . . . . . . . . . 19lidocaine viscous . . . . . . . . . . 21lidocaine/prilocaine . . . . . . . . 19LIDODERM . . . . . . . . . . . . . . . 19linaclotide . . . . . . . . . . . . . . . . . 24linezolid . . . . . . . . . . . . . . . . . . 31LINZESS . . . . . . . . . . . . . . . . . . 24liothyronine . . . . . . . . . . . . . . . 23LIPITOR . . . . . . . . . . . . . . . . . . 11lisinopril . . . . . . . . . . . . . . . . 8, 72lisinopril/hydrochlorothiazide . 8lithium carbonate . . . . . . . . . . 39lithium carbonate extended-

release . . . . . . . . . . . . . . . . 39LITHOBID . . . . . . . . . . . . . . . . . 39lixisenatide . . . . . . . . . . . . . . . . 22LMX-4 . . . . . . . . . . . . . . . . . . . . 19

LO/OVRAL . . . . . . . . . . . . . . . . 34LOCOID . . . . . . . . . . . . . . . . . . 17LODINE . . . . . . . . . . . . . . .12, 32LOESTRIN 1/20 . . . . . . . . . . . 34LOESTRIN 1.5/30 . . . . . . . . . 34LOESTRIN FE 1/20 . . . . . . . . 34LOESTRIN FE 1.5/30 . . . . . . . 34LOFIBRA . . . . . . . . . . . . . . . . . 10LOHIST-D . . . . . . . . . . . . . . . . . 42LOMOTIL . . . . . . . . . . . . . . . . . 24lomustine . . . . . . . . . . . . . . . . . . 4LONITEN . . . . . . . . . . . . . . . . . 11LONSURF . . . . . . . . . . . . . . . . . 4loperamide . . . . . . . . . . . . . . . . 24LOPID . . . . . . . . . . . . . . . . . . . . 10lopinavir/ritonavir . . . . . . . . . . 30LOPRESSOR . . . . . . . . . . . . . . . 9loratadine . . . . . . . . . . . . . . . . . 20lorazepam . . . . . . . . . . . . . . . . 38LORCET . . . . . . . . . . . . . . . . . . 13LORTAB . . . . . . . . . . . . . . . . . . 13LORTAB ELIXIR . . . . . . . . . . . 13losartan . . . . . . . . . . . . . . . . . . . 8losartan/HCTZ . . . . . . . . . . . . . 8LOTENSIN . . . . . . . . . . . . . . . . . 8LOTENSIN HCT . . . . . . . . . . . . 8LOTRIMIN AF . . . . . . . . . . . . . 18LOTRISONE . . . . . . . . . . . . . . . 18lovastatin . . . . . . . . . . . . . . . . . 11LOVAZA . . . . . . . . . . . . . . . . . . 11LOVENOX . . . . . . . . . . . . . . . . . 7loxapine . . . . . . . . . . . . . . . . . . 41LOXITANE . . . . . . . . . . . . . . . . 41LOZOL . . . . . . . . . . . . . . . . . . . 10LUDIOMIL . . . . . . . . . . . . . . . . 39lumacaftor/ivacaftor . . . . . . . . 49LUPRON . . . . . . . . . . . . . . . . . . 5LUPRON DEPOT . . . . . . . . . . . 5LUPRON DEPOT 6-MONTH . . 5

62


Index of Covered DrugsLUPRON DEPOT-PED . . . . . . . 5LURIDE . . . . . . . . . . . . . . . . . . . 47LURIDE LOZI-TABS. . . . . . . . . 47LUVOX . . . . . . . . . . . . . . . . . . . 38LYNPARZA . . . . . . . . . . . . . . . . 6LYSODREN . . . . . . . . . . . . . . . . 6LYSTEDA . . . . . . . . . . . . . . . . . 35

MM-CLEAR WC . . . . . . . . . . . . . 42M-M-R II . . . . . . . . . . . . . . . . . . 51MAALOX . . . . . . . . . . . . . . . . . 25macitentan . . . . . . . . . . . . . . . . 11MACROBID . . . . . . . . . . . . . . . 31MACRODANTIN . . . . . . . . . . . 31MAG-OX . . . . . . . . . . . . . . . . . . 47magnesium citrate soln . . . . . 24magnesium oxide . . . . . . . . . . 47MAPAP COLD TAB . . . . . . . . 44maprotiline . . . . . . . . . . . . . . . . 39maraviroc . . . . . . . . . . . . . . . . . 31MATERNA . . . . . . . . . . . . . . . . 48MATULANE . . . . . . . . . . . . . . . . 7MAVIK . . . . . . . . . . . . . . . . . . . . . 8MAXALT . . . . . . . . . . . . . . . . . . 14MAXALT MLT . . . . . . . . . . . . . 14MAXITROL. . . . . . . . . . . . . . . . 36MAXZIDE . . . . . . . . . . . . . . . . . 10measles, mumps & rubella

virus vaccines for inj . . . . . 51mecasermin . . . . . . . . . . . . . . . 23meclizine . . . . . . . . . . . . . . . . . 24MEDROL . . . . . . . . . . . . . . . . . 21medroxyprogesterone

acetate . . . . . . . . . . . . .33, 35mefloquine . . . . . . . . . . . . . . . . 31MEGACE . . . . . . . . . . . . . . . . . . 6megestrol acetate . . . . . . . . . . . 6MEKINIST . . . . . . . . . . . . . . . . . 5meloxicam . . . . . . . . . . . . .13, 32

melphalan . . . . . . . . . . . . . . . . . 4memantine . . . . . . . . . . . . . . . . 12MENACTRA . . . . . . . . . . . . . . . 51meningococcal (a, c, y, and

w-135) . . . . . . . . . . . . . . . . 51meningococcal (a, c, y, and

w-135) conjugate vaccine . . . . . . . . . . . . . . . . 51

meningococcal (a, c, y, and w-135) oligo conj vac for inj . . . . . . . . . . . . . . . . . . 51

MENOMUNE . . . . . . . . . . . . . . 51MENVEO . . . . . . . . . . . . . . . . . 51meperidine . . . . . . . . . . . . . . . . 13MEPHYTON . . . . . . . . . . . . . . 47MEPRON . . . . . . . . . . . . . . . . . 28mercaptopurine . . . . . . . . . . . . . 4mesalamine . . . . . . . . . . . . . . . 25mesalamine

extended-release . . . . . . . 25mesna . . . . . . . . . . . . . . . . . . . 5, 6MESNEX . . . . . . . . . . . . . . . . 5, 6MESTINON . . . . . . . . . . . . . . . 14MESTINON TIMESPAN . . . . . 14METADATE CD . . . . . . . . . . . . 38METADATE ER . . . . . . . . . . . . 38metaproterenol . . . . . . . . . . . . 46METAPROTERENOL

SYRUP . . . . . . . . . . . . . . . . 46metformin . . . . . . . . . . . . . .22, 23metformin ER . . . . . . . . . . . . . 23metformin/glyburide . . . . . . . . 23methazolamide . . . . . . . . . . . . 37methenamine hippurate . . . . . 46METHERGINE . . . . . . . . . .23, 35methimazole . . . . . . . . . . . . . . 23methocarbamol . . . . . . . . . . . . 33methotrexate . . . . . . . . . . . . . . 32methyldopa . . . . . . . . . . . . . . . 11methylergonovine . . . . . . .23, 35

methylphenidate . . . . . . . . . . . 38methylphenidate extended-

release . . . . . . . . . . . . . . . . 38methylphenidate HCL ER

24hr . . . . . . . . . . . . . . . . . . 38methylprednisolone . . . . . . . . 21metipranolol . . . . . . . . . . . . . . . 36metoclopramide . . . . . . . . . . . 24metolazone . . . . . . . . . . . . . . . 10metoprolol . . . . . . . . . . . . . . . . . 9metoprolol succinate . . . . . . . . 9METROCREAM . . . . . . . . . . . 18METROGEL . . . . . . . . . . . . . . . 18METROGEL-VAGINAL . . . . . . 35METROLOTION . . . . . . . . . . . 18metronidazole . . . . . . 18, 31, 35MEVACOR . . . . . . . . . . . . . . . . 11mexiletine . . . . . . . . . . . . . . . . . . 9MEXITIL . . . . . . . . . . . . . . . . . . . 9MIACALCIN . . . . . . . . . . . . . . . 23MICATIN . . . . . . . . . . . . . . . . . . 18miconazole . . . . . . . . . . . .18, 35MICRO-K 10 . . . . . . . . . . . . . . 49MICRONASE . . . . . . . . . . . . . . 23MICROZIDE . . . . . . . . . . . . . . . 10MIDAMOR . . . . . . . . . . . . . . . . 10midodrine . . . . . . . . . . . . . . . . . 11midostaurin . . . . . . . . . . . . . . . . 5mifepristone . . . . . . . . . . . . . . . 23MIGERGOT

SUPPOSITORIES . . . . . . . 14MILLIPRED . . . . . . . . . . . . . . . 21miltefosine . . . . . . . . . . . . . . . . 28MINIPRESS . . . . . . . . . . . . . . . . 8MINOCIN . . . . . . . . . . . . . . . . . 28minocycline . . . . . . . . . . . . . . . 28minoxidil . . . . . . . . . . . . . . . . . . 11MINUTUSS DR SYP . . . . . . . . 43MIRALAX . . . . . . . . . . . . . . . . . 24MIRAPEX . . . . . . . . . . . . . . . . . 15

63



MIRCETTE . . . . . . . . . . . . . . . . 33mirtazapine . . . . . . . . . . . . . . . 39misoprostol . . . . . . . . . . . . . . . 26mitotane . . . . . . . . . . . . . . . . . . . 6MOBIC . . . . . . . . . . . . . . . .13, 32MODICON . . . . . . . . . . . . . . . . 34MODURETIC . . . . . . . . . . . . . . 10mometasone . . . . . . . . . . .17, 45mometasone furoate . . . . . . . 17MONISTAT 3 . . . . . . . . . . . . . . 35MONISTAT-DERM . . . . . . . . . . 18MONOPRIL . . . . . . . . . . . . . . . . 8MONOPRIL-HCT . . . . . . . . . . . . 8montelukast . . . . . . . . . . . . . . . 46morphine . . . . . . . . . . . . . . . . . 13morphine extended-release . . 13MOTRIN . . . . . . . . . . . . . . .13, 32MOZOBIL . . . . . . . . . . . . . . . . . . 7MS CONTIN . . . . . . . . . . . . . . . 13MSIR . . . . . . . . . . . . . . . . . . . . . 13MUCINEX . . . . . . . . . . . . . . . . . 43MUCINEX D . . . . . . . . . . . . . . . 43MUCINEX DM . . . . . . . . . . . . . 43MUCOMYST . . . . . . . . . . . . . . 49MULTI SYMPTOM TAB COLD

RLF . . . . . . . . . . . . . . . . . . . 44multivitamins/fluoride/±iron . 47multivitamins/minerals . . . . . . 47mupirocin . . . . . . . . . . . . . . . . . 17MURO 128 . . . . . . . . . . . . . . . 37MYAMBUTOL . . . . . . . . . . . . . 27MYCELEX . . . . . . . . . . . . .18, 28MYCOBUTIN . . . . . . . . . . . . . . 28mycophenolate mofetil . . . . . . . 6mycophenolate sodium . . . . . . 6MYCOSTATIN . . . . . . . . . .18, 28MYFORTIC. . . . . . . . . . . . . . . . . 6MYLANTA . . . . . . . . . . . . . . . . 25MYLERAN . . . . . . . . . . . . . . . . . 4MYORISAN . . . . . . . . . . . . . . . 16

MYSOLINE . . . . . . . . . . . . . . . . 16mytesi . . . . . . . . . . . . . . . . . . . . 24

Nnabumetone . . . . . . . . . . . . . . 13naloxone . . . . . . . . . . . . . . .14, 40NALOXONE INJ . . . . . . . . . . . 40naltrexone . . . . . . . . . . . . .38, 40NAMENDA . . . . . . . . . . . . . . . . 12naphazoline HCL . . . . . . . . . . 36naphazoline/glycerin . . . . . . . 36NAPROSYN . . . . . . . . . . . .13, 33naproxen . . . . . . . . . . . . . .13, 33naproxen delayed release 13, 33naratriptan . . . . . . . . . . . . . . . . 14NARCAN NASAL SPRAY . . . 40NASACORT ALLERGY

24 HOUR . . . . . . . . . . . . . . 20NASALCROM . . . . . . . . . . . . . 21nateglinide . . . . . . . . . . . . . . . . 23NATROBA . . . . . . . . . . . . . . . . 19NAVANE . . . . . . . . . . . . . . . . . . 41NEBUPENT . . . . . . . . . . . . . . . 28NEBUSAL . . . . . . . . . . . . . . . . 49nelfinavir . . . . . . . . . . . . . . . . . . 30NEO-SYNEPHRINE . . . . . . . . 21neomycin sulfate . . . . . . . . . . . 31neomycin/bacitracin/

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

bacitracin . . . . . . . . . . . . . . 17neomycin/polymyxin B/

dexamethasone . . . . . . . . 36neomycin/polymyxin B/

gramicidin . . . . . . . . . . . . . 37neomycin/polymyxin B/

hydrocortisone . . . . . .20, 36NEORAL . . . . . . . . . . . . . . . . . . 6NEOSPORIN . . . . . . . . . . .17, 37NEPHROCAPS . . . . . . . . . . . . 48NEPTAZANE . . . . . . . . . . . . . . 37

NESINA . . . . . . . . . . . . . . . . . . 22NESTABS . . . . . . . . . . . . . . . . . 48NEULASTA . . . . . . . . . . . . . . . . 7NEUMEGA . . . . . . . . . . . . . . . . . 7NEURONTIN . . . . . . . . . . . . . . 15NEUTROGENA OIL FREE

ACNE WASH . . . . . . . . . . . 17nevirapine . . . . . . . . . . . . . . . . 29nevirapine ER . . . . . . . . . . . . . 29NEXAVAR . . . . . . . . . . . . . . . . . 5niacin . . . . . . . . . . . . . . . . . . . . 11niacin extended-release . . . . . 11NIACOR . . . . . . . . . . . . . . . . . . 11NIASPAN . . . . . . . . . . . . . . . . . 11nicardipine . . . . . . . . . . . . . . . . . 9NICODERM CQ . . . . . . . . . . . 41NICORETTE OTC . . . . . . . . . . 41nicotine . . . . . . . . . . . . . . . . . . . 41nicotine polacrilex gum . . . . . 41nicotine polacrilex lozenge . . 41nifedipine . . . . . . . . . . . . . . . . . . 9nifedipine extended-release . . 9nilotinib . . . . . . . . . . . . . . . . . . . . 5nimodipine . . . . . . . . . . . . . . . . . 9NIMOTOP. . . . . . . . . . . . . . . . . . 9NINLARO . . . . . . . . . . . . . . . . . . 5niraparib . . . . . . . . . . . . . . . . . . . 6nitisinone . . . . . . . . . . . . . . . . . 23NITRO-DUR . . . . . . . . . . . . . . . 11nitrofurantoin

extended-release . . . . . . . 31nitrofurantoin macrocrystals . 31nitrofurantoin susp . . . . . . . . . 31nitroglycerin . . . . . . . . . . . . . . . 11NITROSTAT . . . . . . . . . . . . . . . 11NITYR . . . . . . . . . . . . . . . . . . . . 23NIX CREME RINSE . . . . . . . . . 19NIZORAL . . . . . . . . . . 18, 19, 28NIZORAL SHAMPOO. . . . . . . 19NOLVADEX . . . . . . . . . . . . . . . . 5

64


Index of Covered DrugsNORCO . . . . . . . . . . . . . . . . . . 13NORDETTE . . . . . . . . . . . . . . . 34norelgestromin/EE . . . . . . . . . 34norethindrone . . . . . . . . . . 33-35norethindrone acetate . . .34, 35norethindrone acetate/EE . . . 34norethindrone acetate/EE/

iron . . . . . . . . . . . . . . . . . . . 34norethindrone/EE . . . . . . .33, 34norethindrone/ME . . . . . . . . . 34norgestimate/EE . . . . . . . . . . . 34norgestrel/EE . . . . . . . . . . . . . 34NORPACE . . . . . . . . . . . . . . . 8, 9NORPACE CR . . . . . . . . . . . . . . 9NORPRAMIN . . . . . . . . . . . . . . 39nortriptyline . . . . . . . . . . . . . . . 39NORVASC . . . . . . . . . . . . . . . . . 9NORVIR . . . . . . . . . . . . . . . . . . 31NOVAREL . . . . . . . . . . . . . . . . 35NOVOLIN 70/30 . . . . . . . . . . . 22NOVOLIN N . . . . . . . . . . . . . . . 22NOVOLIN R . . . . . . . . . . . . . . . 22NOVOLOG MIX 70/30 . . . . . . 22NULYTELY . . . . . . . . . . . . . . . . 24NUVARING . . . . . . . . . . . . . . . 33NUVIGIL . . . . . . . . . . . . . . . . . . 12nystatin . . . . . . . . . . . . . . . .18, 28NYTOL QUICK CAPS . . . . . . . 40

OOCEAN NASAL SPRAY . . . . . 21octreotide . . . . . . . . . . . . . . . . . . 6OCUFEN . . . . . . . . . . . . . . . . . 36OCUFLOX . . . . . . . . . . . . . . . . 37ODEFSEY. . . . . . . . . . . . . . . . . 30ODOMZO . . . . . . . . . . . . . . . . . . 7ofloxacin . . . . . . . . . . . 20, 27, 37OGEN . . . . . . . . . . . . . . . . . . . . 35olanzapine . . . . . . . . . . . . . . . . 41olaparib . . . . . . . . . . . . . . . . . . . 6

olodaterol . . . . . . . . . . . . . . . . . 45olsalazine sodium . . . . . . . . . . 25omalizumab . . . . . . . . . . . . . . . 45ombitasvir/ paritaprevir/

ritonavir . . . . . . . . . . . .28, 29omega 3 acid ethyl esters . . . 11omeprazole delayed-release . 25OMNICEF . . . . . . . . . . . . . . . . . 27ondansetron . . . . . . . . . . . . . . 24One Touch Systems . . . . . . . . 22One Touch Test Strips . . . . . . 22ONFI . . . . . . . . . . . . . . . . . . . . . 15oprelvekin . . . . . . . . . . . . . . . . . 7OPSUMIT . . . . . . . . . . . . . . . . . 11OPTIPRANOLOL . . . . . . . . . . 36OPTIVAR . . . . . . . . . . . . . . . . . 35ORAP . . . . . . . . . . . . . . . . . . . . 41ORAPRED . . . . . . . . . . . . . . . . 21ORKAMBI . . . . . . . . . . . . . . . . 49ORPHENADRINE CITRATE

TAB SR . . . . . . . . . . . . . . . 33orphenadrine ER . . . . . . . . . . 33ORTHO COIL . . . . . . . . . . . . . 33ortho diaphragm . . . . . . . . . . . 33ORTHO EVRA . . . . . . . . . . . . . 34ORTHO FLAT . . . . . . . . . . . . . 33ORTHO FLEX . . . . . . . . . . . . . 33ORTHO MICRONOR . . . . . . . 34ORTHO TRI-CYCLEN . . . . . . . 34ORTHO-CEPT . . . . . . . . . . . . . 34ORTHO-CYCLEN . . . . . . . . . . 34ORTHO-NOVUM 1/35 . . . . . . 34ORTHO-NOVUM 1/50 . . . . . . 34ORTHO-NOVUM 10/11 . . . . 33ORTHO-NOVUM 7/7/7 . . . . . 34ORUDIS . . . . . . . . . . . . . . .13, 32OS-CAL . . . . . . . . . . . . . . . . . . 47oseltamivir . . . . . . . . . . . . . . . . 29OSENI . . . . . . . . . . . . . . . . . . . . 22OVCON 50 . . . . . . . . . . . . . . . . 34

OVIDREL . . . . . . . . . . . . . . . . . 35OVRAL . . . . . . . . . . . . . . . . . . . 34oxaprozin . . . . . . . . . . . . . .13, 33oxazepam . . . . . . . . . . . . . . . . 38oxcarbazepine . . . . . . . . . . . . . 15oxybutynin chloride . . . . . . . . 46oxybutynin IR . . . . . . . . . . . . . . 46oxybutynin patch. . . . . . . . . . . 46oxycodone . . . . . . . . . . . . . . . . 13oxycodone/acetaminophen . 13oxycodone/aspirin . . . . . . . . . 13OXYFAST . . . . . . . . . . . . . . . . . 13oxymetazoline . . . . . . . . . . . . . 21oxymorphone ER . . . . . . . . . . 14OXYTROL FOR WOMEN OTC

PATCH . . . . . . . . . . . . . . . . 46

Ppalbociclib . . . . . . . . . . . . . . . . . 5paliperidone . . . . . . . . . . . . . . . 41palivizumab . . . . . . . . . . . . . . . 31PAMELOR . . . . . . . . . . . . . . . . 39pancrelipase . . . . . . . . . . . . . . 26panobinostat . . . . . . . . . . . . . . . 4PANRETIN . . . . . . . . . . . . . . . . . 6pantoprazole . . . . . . . . . . . . . . 25PARAFON FORTE DSC . . . . . 33PARNATE . . . . . . . . . . . . . . . . . 39paromomycin . . . . . . . . . . . . . 31paroxetine . . . . . . . . . . . . . . . . 39pasireotide . . . . . . . . . . . . . . . . . 6PAXIL . . . . . . . . . . . . . . . . . . . . 39pazopanib . . . . . . . . . . . . . . . . . 5PEDIACARE LIQ MULTI-SY . . 44PEDIALYTE . . . . . . . . . . . . . . . 47PEDIAPRED . . . . . . . . . . . . . . . 21PEDIAZOLE . . . . . . . . . . . . . . . 27peg 3350/electrolytes . . . . . . 24peg 3350/sodium bicarbonate/

sodium chloride . . . . . . . . 24

65



peg 3350/sodium bicarbonate/sodium chloride/potassium chloride . . . . . . . . . . . . . . . 24

PEGASYS . . . . . . . . . . . . . . . . . 29PEGASYS PROCLICK . . . . . . 29pegfilgrastim . . . . . . . . . . . . . . . 7peginterferon alfa-2a . . . . . . . 29peginterferon alfa-2b . . . . . . . . 6peginterferon beta-1a . . . . . . . 14pegvisomant . . . . . . . . . . . . . . 23penicillamine . . . . . . . . . . . . . . 32penicillin VK . . . . . . . . . . . . . . . 27PENLAC SOLUTION 8% . . . . 18pentamidine isethionate for

nebulization . . . . . . . . . . . . 28pentazocine/naloxone . . . . . . 14pentosan polysulfate sodium 46pentoxifylline

extended-release . . . . . . . . 7PEPCID . . . . . . . . . . . . . . . . . . 25PEPCID AC . . . . . . . . . . . . . . . 25PERCOCET . . . . . . . . . . . . . . . 13PERCODAN . . . . . . . . . . . . . . . 13PERIDEX . . . . . . . . . . . . . . . . . 21permethrin . . . . . . . . . . . . . . . . 19perphenazine . . . . . . . . . .39, 41PERSANTINE . . . . . . . . . . . . . . 7phenazopyridine . . . . . . . . . . . 46PHENERGAN . . . . . . . . . .24, 43PHENERGAN DM . . . . . . . . . . 43phenobarbital . . . . . . . . . . . . . 16phenylephrine . . . . . . . 21, 41-44phenylephrine/

brompheniramine/dextromethorphan . . . . . . 43

phenylephrine/chlorpheniramine/ dextromethorphan . . .43, 44

phenylephrine/chlorpheniramine/dihydrocodeine . . . . . . . . . 44

phenylephrine/dextromethorphan . . . . . . 44

phenylephrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 44

phenylephrine/ephed/CPM w/carbetapentane . . . . . . 44

phenylephrine/guaifenesin . . 44phenylephrine/pyrilamine

w/hydrocodone . . . . . . . . 44PHENYTEK . . . . . . . . . . . . . . . 16phenytoin . . . . . . . . . . . . . . . . . 16phenytoin sodium extended . 16PHILLIPS COLON HEALTH . 26PHOS-FLUR . . . . . . . . . . . . . . 47phytonadione. . . . . . . . . . . . . . 47pilocarpine . . . . . . . . . . . . .21, 37pimozide . . . . . . . . . . . . . . . . . 41PIN-X . . . . . . . . . . . . . . . . . . . . . 27piroxicam . . . . . . . . . . . . . .13, 33PLAN B ONE STEP . . . . . . . . 33PLAQUENIL . . . . . . . . . . . .31, 32PLAVIX . . . . . . . . . . . . . . . . . . . . 7PLEGRIDY . . . . . . . . . . . . . . . . 14PLENDIL . . . . . . . . . . . . . . . . . . 9plerixafor . . . . . . . . . . . . . . . . . . 7PLETAL . . . . . . . . . . . . . . . . . . . 7PLEXION . . . . . . . . . . . . . . . . . 17pneumococcal 13-valent

conjugate . . . . . . . . . . . . . . 51pneumococcal vaccine

polyvalent. . . . . . . . . . . . . . 51PNEUMOVAX . . . . . . . . . . . . . 51PNEUMOVAX 23 . . . . . . . . . . 51podofilox . . . . . . . . . . . . . . . . . 19POLY-VI-FLOR . . . . . . . . . . . . . 47polyethylene glycol 3350 . . . . 24polymyxin B/bacitracin . .17, 37

polymyxin B/trimethoprim . . . 37POLYSPORIN . . . . . . . . . . . . . 37POLYTRIM . . . . . . . . . . . . . . . . 37pomalidomide . . . . . . . . . . . . . . 6POMALYST . . . . . . . . . . . . . . . . 6ponatinib . . . . . . . . . . . . . . . . . . 5potassium chloride . . . . . .24, 49potassium chloride extended-

release . . . . . . . . . . . . . . . . 49potassium iodide . . . . . . . . . . 49povidone-iodine . . . . . . . . . . . 31praluent . . . . . . . . . . . . . . . . . . 11pramipexole . . . . . . . . . . . . . . . 15PRANDIN . . . . . . . . . . . . . . . . . 23praziquantel . . . . . . . . . . . . . . . 26prazosin . . . . . . . . . . . . . . . . . . . 8PRECOSE . . . . . . . . . . . . . . . . 22PRED FORTE . . . . . . . . . . . . . 36prednicarbate . . . . . . . . . . . . . 17prednisolone . . . . . . . . . . .21, 36prednisolone acetate . . . . . . . 36prednisolone phosphate . . . . 36prednisolone sodium

phosphate . . . . . . . . . . . . . 21prednisone . . . . . . . . . . . . . . . . 21PRELONE . . . . . . . . . . . . . . . . 21PREMARIN . . . . . . . . . . . . . . . 35PREMPHASE . . . . . . . . . . . . . 35PREMPRO . . . . . . . . . . . . . . . . 35prenat w/o A w/fecbn-fegl-DSS-

FA & DHA . . . . . . . . . . . . . . 48prenat-FE Bis-FE prot succ-FA-

CA & omega 3 . . . . . .47, 48prenat-FE bis-FE prot succ-FA-

CA & omega DR . . . . . . . . 48prenatal vit w/FE bisglycinate

chelate-FA . . . . . . . . . . . . . 48prenatal vit w/FE polysac cmplx-

FA . . . . . . . . . . . . . . . . . . . . 48prenatal vitamins w/folic acid 48

66



prenatal w/o A w/FE carbonyl-FE gluc-DSS-FA . . . . . . . . 48

PREVACID . . . . . . . . . . . . . . . . 25PREVACID SOLUTAB . . . . . . 25PREVIDENT . . . . . . . . . . . . . . . 47PREVNAR 13 . . . . . . . . . . . . . 51PREZCOBIX . . . . . . . . . . . . . . 31PREZISTA . . . . . . . . . . . . . . . . 30PRILOSEC . . . . . . . . . . . . . . . . 25primaquine. . . . . . . . . . . . . . . . 31primidone . . . . . . . . . . . . . . . . . 16PRINCIPEN . . . . . . . . . . . . . . . 27PROAMATINE . . . . . . . . . . . . . 11probenecid . . . . . . . . . . . . . . . 33probiotics . . . . . . . . . . . . . . . . . 26procarbazine . . . . . . . . . . . . . . . 7PROCARDIA . . . . . . . . . . . . . . . 9PROCARDIA XL . . . . . . . . . . . . 9prochlorperazine . . . . . . . . . . . 24PROCRIT . . . . . . . . . . . . . . . . . . 7PROCTOSOL HC CREAM

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

2.5% . . . . . . . . . . . . . . . . . . 19progesterone micronized

cap . . . . . . . . . . . . . . . . . . . 34PROGRAF . . . . . . . . . . . . . . . . . 6PROLIXIN . . . . . . . . . . . . . . . . . 41PROLIXIN DECANOATE . . . . 41PROMACTA . . . . . . . . . . . . . . . 49promethazine . . . . . . 24, 42, 43PROMETHAZINE SYP DM . . 43PROMETHAZINE VC

W/CODEINE . . . . . . . . . . . 42PROMETHAZINE

W/CODEINE . . . . . . . . . . . 42PROMETRIUM . . . . . . . . . . . . 34propafenone . . . . . . . . . . . . . . . 9propantheline . . . . . . . . . . . . . 46propranolol . . . . . . . . . . . . . 9, 14

propranolol ER 24HR . . . . . . . 9propranolol/HCTZ . . . . . . . . . . 9propylthiouracil . . . . . . . . . . . . 23PROSCAR . . . . . . . . . . . . . . . . 46PROTONIX . . . . . . . . . . . . . . . . 25PROTOPIC 0.03% . . . . . . . . . 19PROTOPIC 0.1% . . . . . . . . . . . 20PROVENTIL . . . . . . . . . . . . . . . 45PROVERA . . . . . . . . . . . . . . . . 35PROZAC . . . . . . . . . . . . . . . . . 39PRUET DHA PAK SETONET

PAK . . . . . . . . . . . . . . . . . . . 48PRUET DHAEC PAK . . . . . . . 48PSE/GG . . . . . . . . . . . . . . . . . . 43pseudoephedrine tan/

dexchlorphen tan/DM tan 45pseudoephedrine/

acetaminophen/dextromethorphan . . . . . . 44

pseudoephedrine/chlorpheniramine/dextromethorphan . . . . . . 44

pseudoephedrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 44

pseudoephedrine/iburprofen 44PULMICORT RESPULES . . . 45PULMOZYME . . . . . . . . . . . . . 49PURINETHOL . . . . . . . . . . . . . . 4pyrantel pamoate . . . . . . . . . . 27pyrazinamide . . . . . . . . . . . . . . 27pyrethrins/piperonyl butoxide

shampoo . . . . . . . . . . . . . . 19PYRIDIUM . . . . . . . . . . . . . . . . 46pyridostigmine . . . . . . . . . . . . . 14pyridostigmine

extended-release . . . . . . . 14pyrilamine tan/phenyleph tan 45pyrimethamine . . . . . . . . . . . . 31

QQUESTRAN . . . . . . . . . . . . . . . 10QUESTRAN-LIGHT . . . . . . . . . 10quetiapine . . . . . . . . . . . . . . . . 41quinapril . . . . . . . . . . . . . . . . . . . 8quinapril/hydrochlorothiazide . 8QUINIDINE GLUCONATE EXT-

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

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

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

release . . . . . . . . . . . . . . . . . 9QVAR REDIHALER . . . . . . . . . 45

RR-TANNAMINE . . . . . . . . . . . . 42raloxifene . . . . . . . . . . . . . . . . . 23raltegravir . . . . . . . . . . . . . . . . . 29raltegravir susp . . . . . . . . . . . . 29ramipril . . . . . . . . . . . . . . . . . . . . 8ranitidine . . . . . . . . . . . . . . . . . 25ranitidine syrup . . . . . . . . . . . . 25RAPAMUNE. . . . . . . . . . . . . . . . 6RAVICTI . . . . . . . . . . . . . . . . . . 50RAZADYNE . . . . . . . . . . . . . . . 12REBETOL/COPEGUS . . . . . . 29RECOMBIVAX HB . . . . . . . . . 50REESE’S PINWORM

MEDICINE . . . . . . . . . . . . . 27REGLAN . . . . . . . . . . . . . . . . . 24regorafenib . . . . . . . . . . . . . . . . 5REGRANEX . . . . . . . . . . . . . . . 19RELAFEN . . . . . . . . . . . . . . . . . 13RELENZA. . . . . . . . . . . . . . . . . 29RELION 70/30 . . . . . . . . . . . . 22RELION N . . . . . . . . . . . . . . . . 22RELION R . . . . . . . . . . . . . . . . 22

67



REMERON . . . . . . . . . . . . . . . . 39RENVELA . . . . . . . . . . . . . . . . 49repaglinide . . . . . . . . . . . . . . . . 23REQUIP . . . . . . . . . . . . . . . . . . 15RESCRIPTOR . . . . . . . . . . . . . 29RESPERAL-DM . . . . . . . . . . . . 42RESTORIL . . . . . . . . . . . . . . . . 40RETIN-A . . . . . . . . . . . . . . . . . . 17RETROVIR . . . . . . . . . . . . . . . . 30REVATIO . . . . . . . . . . . . . . . . . 11REVIA . . . . . . . . . . . . . . . . .38, 40REVLIMID . . . . . . . . . . . . . . . . . 6REYATAZ . . . . . . . . . . . . . . . . . 30REYATAZ POWDER

PACKET . . . . . . . . . . . . . . . 30ribavirin . . . . . . . . . . . . . . . . . . . 29RID SHAMPOO . . . . . . . . . . . . 19RIDAURA . . . . . . . . . . . . . . . . . 32rifabutin . . . . . . . . . . . . . . . . . . 28RIFADIN . . . . . . . . . . . . . . . . . . 27rifampin . . . . . . . . . . . . . . . . . . 27rilpivirine . . . . . . . . . . . . . . . 29-31RILUTEK . . . . . . . . . . . . . . . . . 12riluzole . . . . . . . . . . . . . . . . . . . 12rimantadine . . . . . . . . . . . . . . . 29riociguat . . . . . . . . . . . . . . . . . . 11RISA-BID . . . . . . . . . . . . . . . . . 26RISAQUAD . . . . . . . . . . . . . . . . 26RISPERDAL . . . . . . . . . . . . . . . 41RISPERDAL CONSTA . . . . . . 41RISPERDAL SOLUTION . . . . 41risperidone . . . . . . . . . . . . . . . . 41risperidone oral soln . . . . . . . . 41RITALIN . . . . . . . . . . . . . . . . . . 38RITALIN LA . . . . . . . . . . . . . . . 38ritonavir . . . . . . . . . . . . . . . . 28-31rivaroxaban . . . . . . . . . . . . . . . . 7rivastigmine . . . . . . . . . . . . . . . 12rizatriptan . . . . . . . . . . . . . . . . . 14RMS . . . . . . . . . . . . . . . . . . . . . 13

ROBAXIN . . . . . . . . . . . . . . . . . 33ROBINUL . . . . . . . . . . . . . . . . . 25ROBITUSSIN . . . . . . . . . . . 42-44ROBITUSSIN CF . . . . . . . . . . . 43ROBITUSSIN DM . . . . . . . . . . 43ROBITUSSIN LIQ CGH/

ALRG . . . . . . . . . . . . . . . . . 44ROBITUSSIN LIQ

CGH/CLD . . . . . . . . . .42, 44ROBITUSSIN LIQ

CGH/CONG . . . . . . . . . . . 43ROBITUSSIN LIQ HD/CHST . 44ROBITUSSIN LIQ PED

NGHT . . . . . . . . . . . . . . . . . 44ROBITUSSIN PE . . . . . . . . . . . 43ROBITUSSIN PED LIQ CGH/

COLD . . . . . . . . . . . . . . . . . 42ROBITUSSIN PED SYP . . . . . 43ROBITUSSIN SYP CHST

CNG . . . . . . . . . . . . . . . . . . 43ROBITUSSIN SYP MAX-ST . . 43ROCALTROL . . . . . . . . . . . . . . 47ROCALTROL SOLUTION . . . 47RONDEC DM . . . . . . . . . .43, 44RONDEC DM DROPS . . . . . . 44RONDEC DROPS . . . . . . . . . . 42RONDEC SYRUP . . . . . . . . . . 42ropinirole . . . . . . . . . . . . . . . . . 15ROWASA . . . . . . . . . . . . . . . . . 25ROXICODONE . . . . . . . . . . . . 13RUBRACA . . . . . . . . . . . . . . . . . 7rucaparib . . . . . . . . . . . . . . . . . . 7rufinamide . . . . . . . . . . . . . . . . 16ruxolitinib . . . . . . . . . . . . . . . . . . 5RYDAPT . . . . . . . . . . . . . . . . . . . 5RYNA-12 S . . . . . . . . . . . . . . . 45RYNATAN PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 42RYNATUSS PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 44RYTHMOL . . . . . . . . . . . . . . . . . 9

SSABRIL . . . . . . . . . . . . . . . . . . . 16sacubitril/valsartan . . . . . . . . . . 8SALAGEN . . . . . . . . . . . . . . . . 21salicylic acid . . . . . . . . . . .17, 18saline nasal spray 0.65% . . . . 21salsalate . . . . . . . . . . . . . . . . . . 33SANCTURA . . . . . . . . . . . . . . . 46SANDIMMUNE . . . . . . . . . . . . . 6SANDOSTATIN . . . . . . . . . . . . . 6sapropterin . . . . . . . . . . . . .23, 24sapropterin powder . . . . . . . . 24saquinavir mesylate . . . . . . . . 31sargramostim. . . . . . . . . . . . . . . 7sarilumab . . . . . . . . . . . . . . . . . 32SCALPICIN . . . . . . . . . . . . . . . 18SEASONALE . . . . . . . . . . . . . . 33SECTRAL . . . . . . . . . . . . . . . . . . 9secukinumab . . . . . . . . . . . . . . 32SEGLUROMET . . . . . . . . . . . . 22selegiline . . . . . . . . . . . . . . . . . 15selenium sulfide . . . . . . . . . . . 19SELSUN . . . . . . . . . . . . . . . . . . 19SELZENTRY . . . . . . . . . . . . . . 31sennosides . . . . . . . . . . . . . . . 24SENOKOT . . . . . . . . . . . . . . . . 24SENSIPAR . . . . . . . . . . . . . . . . 23SERAX . . . . . . . . . . . . . . . . . . . 38SEROMYCIN . . . . . . . . . . . . . . 28SEROQUEL . . . . . . . . . . . . . . . 41sertraline . . . . . . . . . . . . . . . . . 39sevelamer . . . . . . . . . . . . . . . . . 49SHINGRIX . . . . . . . . . . . . . . . . 51SIGNIFOR . . . . . . . . . . . . . . . . . 6sildenafil . . . . . . . . . . . . . . . . . . 11SILVADENE . . . . . . . . . . . . . . . 17silver sulfadiazine . . . . . . . . . . 17simvastatin . . . . . . . . . . . . . . . . 11SINEMET . . . . . . . . . . . . . . . . . 15

68


Index of Covered DrugsSINEMET CR . . . . . . . . . . . . . . 15SINEQUAN . . . . . . . . . . . . . . . 39SINGULAIR . . . . . . . . . . . . . . . 46sirolimus . . . . . . . . . . . . . . . . . . . 6SIRTURO . . . . . . . . . . . . . . . . . 31sodium chloride for nebulizer 49sodium chloride hypertonic . 37sodium citrate/citric acid . . . . 46sodium phenylbutyrate . . . . . 50sodium polystyrene sulfonate 11sofosbuvir/velpatasvir. . . . . . . 29SOLIQUA . . . . . . . . . . . . . . . . 21somatropin . . . . . . . . . . . . . . . . 23SOMAVERT . . . . . . . . . . . . . . . 23SONATA . . . . . . . . . . . . . . . . . . 40sonidegib . . . . . . . . . . . . . . . . . . 7sorafenib . . . . . . . . . . . . . . . . . . 5SORIATANE . . . . . . . . . . . . . . . 18sotalol . . . . . . . . . . . . . . . . . . . . . 9sotalol AF . . . . . . . . . . . . . . . . . . 9spacers . . . . . . . . . . . . . . . . . . . 50spinosad . . . . . . . . . . . . . . . . . 19spironolactone. . . . . . . . . . . . . 10spironolactone/

hydrochlorothiazide . . . . . 10SPORANOX . . . . . . . . . . . . . . . 28SPRYCEL . . . . . . . . . . . . . . . . . . 4SSKI . . . . . . . . . . . . . . . . . . . . . 49STADOL . . . . . . . . . . . . . . . . . . 13STARLIX . . . . . . . . . . . . . . . . . . 23STATUSS DM SYP . . . . . . . . . 43stavudine . . . . . . . . . . . . . . . . . 30STEGLATRO . . . . . . . . . . . . . . 22STELAZINE . . . . . . . . . . . . . . . 41STIOLTO RESPIMAT . . . . . . . 45STIVARGA . . . . . . . . . . . . . . . . . 5STRENSIQ . . . . . . . . . . . . . . . . 23STRIBILD . . . . . . . . . . . . . . . . . 31STRIVERDI RESPIMAT . . . . . 45

STROMECTOL . . . . . . . . . . . . 26SUBOXONE . . . . . . . . . . . . . . . 40SUBUTEX . . . . . . . . . . . . . . . . 40succimer . . . . . . . . . . . . . . . . . 49sucralfate . . . . . . . . . . . . . . . . . 25sulcralfate . . . . . . . . . . . . . . . . . 25SULFACET-R . . . . . . . . . . . . . . 17sulfacetamide . . . . . . 17, 36, 37sulfacetamide/pred phos . . . 36sulfacetamide/sulfur . . . . . . . . 17sulfamethoxazole/

trimethoprim, DS . . . . . . . 28sulfasalazine . . . . . . . 25, 26, 32sulfasalazine

delayed-release . . . . . .26, 32sulindac . . . . . . . . . . . . . . .13, 33sumatriptan . . . . . . . . . . . . . . . 14sunitinib . . . . . . . . . . . . . . . . . . . 5SUSTIVA . . . . . . . . . . . . . . . . . . 29SUTENT . . . . . . . . . . . . . . . . . . . 5SYLATRON . . . . . . . . . . . . . . . . 6SYMFI . . . . . . . . . . . . . . . . . . . . 30SYMFI LO . . . . . . . . . . . . . . . . . 30SYMMETREL . . . . . . . . . .15, 29SYNAGIS . . . . . . . . . . . . . . . . . 31SYNALAR . . . . . . . . . . . . . . . . 17SYNTHROID . . . . . . . . . . . . . . 23

TT-STAT . . . . . . . . . . . . . . . . . . . 16TABLOID . . . . . . . . . . . . . . . . . . 4tacrolimus . . . . . . . . . . 6, 19, 20TAFINLAR . . . . . . . . . . . . . . . . . 4TAGAMET . . . . . . . . . . . . . . . . 25TALWIN NX . . . . . . . . . . . . . . . 14TAMBOCOR . . . . . . . . . . . . . . . 9TAMIFLU . . . . . . . . . . . . . . . . . 29tamoxifen . . . . . . . . . . . . . . . . . . 5tamsulosin . . . . . . . . . . . . . . . . 46

TANAFED DMX SUSPENSION . . . . . . . . . . 45

TAPAZOLE . . . . . . . . . . . . . . . . 23TARCEVA . . . . . . . . . . . . . . . . . . 4TARGRETIN . . . . . . . . . . . . . . . . 6TASIGNA . . . . . . . . . . . . . . . . . . 5TASMAR . . . . . . . . . . . . . . . . . . 15TECFIDERA . . . . . . . . . . . . . . . 14TECHNIVIE . . . . . . . . . . . . . . . 29teduglutide . . . . . . . . . . . . . . . . 26TEGRETOL . . . . . . . . . . . . . . . 15TEGRETOL-XR . . . . . . . . . . . . 15temazepam . . . . . . . . . . . . . . . 40TEMODAR . . . . . . . . . . . . . . . . . 4TEMOVATE . . . . . . . . . . . . . . . 18temozolomide . . . . . . . . . . . . . . 4TENEX . . . . . . . . . . . . . . . . . . . . 8TENIVAC . . . . . . . . . . . . . . . . . 51tenofovir . . . . . . . . . . . . . . .30, 31TENORETIC . . . . . . . . . . . . . . . 9TENORMIN . . . . . . . . . . . . . . . . 9TERAZOL 3/7 . . . . . . . . . . . . . 35terazosin . . . . . . . . . . . . . . . . 8, 46terbinafine . . . . . . . . . . . . .18, 28terbutaline . . . . . . . . . . . . . . . . 46terconazole . . . . . . . . . . . . . . . 35teriflunomide . . . . . . . . . . . . . . 14TESSALON . . . . . . . . . . . . . . . 41TESTOSTERONE 1%

TOPICAL GEL . . . . . . . . . . 21testosterone cypionate . . . . . . 21testosterone enanthate . . . . . . 21testosterone gel topical tube,

packet, and pump bottle . 21tet tox-diph-acell pertuss ad . 51TET/DIP TOX INJ . . . . . . . . . . 51tetanus immune globulin

(human) . . . . . . . . . . . . . . . 51tetanus-diphtheria toxoids

(td) . . . . . . . . . . . . . . . . . . . 51

69



tetrabenazine . . . . . . . . . . . . . . 16tetrahydrozoline/zinc sulfate . 36thalidomide . . . . . . . . . . . . . . . . 6THALOMID . . . . . . . . . . . . . . . . 6THEOCHRON . . . . . . . . . . . . . 46theophylline . . . . . . . . . . . . . . . 46theophylline

extended-release . . . . . . . 46thioguanine . . . . . . . . . . . . . . . . 4thiothixene . . . . . . . . . . . . . . . . 41THORAZINE . . . . . . . . . . . . . . 41tiagabine . . . . . . . . . . . . . . . . . 16TIAZAC . . . . . . . . . . . . . . . . . . . 10TIGAN . . . . . . . . . . . . . . . . . . . . 24TIKOSYN . . . . . . . . . . . . . . . . . . 9timolol . . . . . . . . . . . . . . . . . . . . 36timolol maleate . . . . . . . . . . . . 36TIMOPTIC . . . . . . . . . . . . . . . . 36TIMOPTIC XE . . . . . . . . . . . . . 36TINACTIN . . . . . . . . . . . . . . . . . 18tiotropium/olodaterol . . . . . . . 45tipranavir . . . . . . . . . . . . . . . . . 31TIVICAY . . . . . . . . . . . . . . . . . . 29tizanidine . . . . . . . . . . . . . . . . . 33TOBRADEX . . . . . . . . . . . . . . . 36tobramycin . . . . . . . . . 36, 37, 49tobramycin neb soln . . . . . . . . 49tobramycin/dexamethasone . 36TOBREX . . . . . . . . . . . . . . . . . . 37TOFRANIL . . . . . . . . . . . . . . . . 39tolazamide . . . . . . . . . . . . . . . . 23tolcapone . . . . . . . . . . . . . . . . . 15TOLINASE . . . . . . . . . . . . . . . . 23tolnaftate . . . . . . . . . . . . . . . . . 18tolterodine . . . . . . . . . . . . . . . . 46TOPAMAX . . . . . . . . . . . . . . . . 16TOPAMAX SPRINKLE . . . . . . 16topiramate . . . . . . . . . . . . . . . . 16topiramate sprinkle caps . . . . 16

topotecan . . . . . . . . . . . . . . . . . . 7TOPROL XL . . . . . . . . . . . . . . . . 9TORADOL . . . . . . . . . . . . . . . . 13toremifene . . . . . . . . . . . . . . . . . 5torsemide . . . . . . . . . . . . . . . . . 10TOUJEO SOLOSTAR . . . . . . . 22TRACLEER . . . . . . . . . . . . . . . 11tramadol . . . . . . . . . . . . . . . . . . 12trametinib . . . . . . . . . . . . . . . . . . 5TRANDATE . . . . . . . . . . . . . . . . 9trandolapril . . . . . . . . . . . . . . . . . 8tranexamic acid . . . . . . . . . . . . 35TRANXENE . . . . . . . . . . . . . . . 38tranylcypromine . . . . . . . . . . . . 39trazodone . . . . . . . . . . . . . . . . . 40TRENTAL . . . . . . . . . . . . . . . . . . 7tretinoin . . . . . . . . . . . . . . . . 7, 17TRI RX . . . . . . . . . . . . . . . . . . . 48TRI-FED X. . . . . . . . . . . . . . . . . 45TRI-NORINYL . . . . . . . . . . . . . 34TRI-VI-FLOR . . . . . . . . . . . . . . . 48TRI-VI-SOL . . . . . . . . . . . . . . . . 48triamcinolone . . . . 17, 18, 20, 21triamcinolone acetonide .17, 18triamcinolone nasal spray . . . 20triamterene/

hydrochlorothiazide . . . . . 10TRIAVIL . . . . . . . . . . . . . . . . . . 39triazolam . . . . . . . . . . . . . . . . . . 40trifluoperazine . . . . . . . . . . . . . 41trifluridine . . . . . . . . . . . . . . . 4, 37trifluridine/tipiracil . . . . . . . . . . . 4trihexyphenidyl . . . . . . . . . . . . 15TRILAFON . . . . . . . . . . . . . . . . 41TRILEPTAL . . . . . . . . . . . . . . . 15TRILYTE . . . . . . . . . . . . . . . . . . 24trimethobenzamide . . . . . . . . 24trimethoprim . . . . . . . 28, 31, 37

TRIOTANN PEDIATRIC SUSP . . . . . . . . . . . . . . . . . 42

tripolidine/pseudoephedrine 45TRIPROL/PSE SYP . . . . . . . . 45TRIUMEQ . . . . . . . . . . . . . . . . . 31TRIVORA . . . . . . . . . . . . . . . . . 34TRIZIVIR . . . . . . . . . . . . . . . . . . 30trospium . . . . . . . . . . . . . . . . . . 46TRULICITY . . . . . . . . . . . . . . . . 22TRUSOPT . . . . . . . . . . . . . . . . 36TRUST NATALCARE

PAK DHA . . . . . . . . . . . . . . 48TRUVADA . . . . . . . . . . . . . . . . 30TUSSI-12 S . . . . . . . . . . . . . . . 42TUSSIN DM . . . . . . . . . . . . . . . 43TYBOST . . . . . . . . . . . . . . . . . . 31TYKERB . . . . . . . . . . . . . . . . . . . 5TYLENOL . . . . . . . . . . 12, 13, 32TYLENOL W/CODEINE . . . . . 13TYMLOS . . . . . . . . . . . . . . . . . 23

UULTRA . . . . . . . . . . . . . . . . . . . 22ULTRA 2, ULTRAMINI . . . . . . 22ULTRAM . . . . . . . . . . . . . . . . . . 12ULTRAVATE . . . . . . . . . . . . . . . 18umeclidinium inhalation . . . . . 45UNI-HIST DROPS . . . . . . . . . . 41UNIPHYL . . . . . . . . . . . . . . . . . 46UNISOM . . . . . . . . . . . . . . . . . . 40UREA 10% CREAM . . . . . . . . 20UREA 10% LOTION . . . . . . . . 20urea 10%, urea 20% . . . . . . . . 20UREA 20% CREAM . . . . . . . . 20urea 40% . . . . . . . . . . . . . . . . . 20UREA 40% LOTION . . . . . . . . 20URECHOLINE . . . . . . . . . . . . . 46UREX . . . . . . . . . . . . . . . . . . . . 46uridine . . . . . . . . . . . . . . . . . . . 24UROXATRAL . . . . . . . . . . . . . . 46

70


Index of Covered Drugsursodiol . . . . . . . . . . . . . . . . . . 26

VVAGIFEM . . . . . . . . . . . . . . . . . 35valacyclovir . . . . . . . . . . . . . . . . 29valbenazine . . . . . . . . . . . . . . . 16VALCYTE . . . . . . . . . . . . . . . . . 28valganciclovir . . . . . . . . . . . . . . 28VALIUM . . . . . . . . . . . . . . .33, 38valproic acid . . . . . . . . . . . . . . 16VALTREX . . . . . . . . . . . . . . . . . 29VANCOCIN HCL . . . . . . . . . . . 28vancomycin HCl . . . . . . . . . . . 28vandetanib . . . . . . . . . . . . . . . . . 5VAQTA . . . . . . . . . . . . . . . . . . . 50varenicline . . . . . . . . . . . . . . . . 41varicella virus vac live for

subcutaneous . . . . . . . . . . 51VARIVAX . . . . . . . . . . . . . . . . . 51VASERETIC . . . . . . . . . . . . . . . . 8VASOCIDIN . . . . . . . . . . . . . . . 36VASOCLEAR . . . . . . . . . . . . . . 36VASOTEC . . . . . . . . . . . . . . . . . . 8VECTICAL . . . . . . . . . . . . . . . . 18VEETIDS . . . . . . . . . . . . . . . . . 27vemurafenib . . . . . . . . . . . . . . . . 5VENCLEXTA . . . . . . . . . . . . . . . 5venetoclax . . . . . . . . . . . . . . . . . 5venlafaxine . . . . . . . . . . . . . . . . 39venlafaxine XR . . . . . . . . . . . . . 39VENTOLIN HFA . . . . . . . . . . . . 45VEPESID . . . . . . . . . . . . . . . . . . 6verapamil . . . . . . . . . . . . . .10, 14verapamil extended-release . . 10VERIO . . . . . . . . . . . . . . . . . . . . 22VERIO, VERIO FLEX, VERIO IQ,

VERIO SYNC . . . . . . . . . . . 22VERZENIO . . . . . . . . . . . . . . . . . 4VESANOID . . . . . . . . . . . . . . . . . 7VFEND . . . . . . . . . . . . . . . . . . . 28

VICODIN . . . . . . . . . . . . . . . . . . 13VICODIN ES . . . . . . . . . . . . . . . 13VIDEX . . . . . . . . . . . . . . . . . . . . 30VIDEX EC . . . . . . . . . . . . . . . . . 30VIEKIRA . . . . . . . . . . . . . . . . . . 28VIEKIRA XR . . . . . . . . . . . . . . . 28vigabatrin powd pack . . . . . . . 16VINATE AZ EX . . . . . . . . . . . . . 48VINATE II . . . . . . . . . . . . . . . . . 48VIRACEPT . . . . . . . . . . . . . . . . 30VIRAMUNE . . . . . . . . . . . . . . . 29VIRAMUNE XR . . . . . . . . . . . . 29VIREAD . . . . . . . . . . . . . . . . . . 30VIROPTIC . . . . . . . . . . . . . . . . . 37VISINE-AC . . . . . . . . . . . . . . . . 36vismodegib . . . . . . . . . . . . . . . . 7VISTARIL . . . . . . . . . . . . . . . . . 20VISTOGARD . . . . . . . . . . . . . . 24vitamin A . . . . . . . . . . . . . . . . . 48vitamin ADC/fluoride/±iron

drops . . . . . . . . . . . . . . . . . 48vitamin B complex/vitamin C/

folic acid . . . . . . . . . . . . . . . 48vitamin B-1 . . . . . . . . . . . . . . . . 48VITAMIN B-12 . . . . . . . . . . . . . 47vitamin B-6 . . . . . . . . . . . . . . . . 48vitamin C . . . . . . . . . . . . . . . . . 48VITAMIN D 1000 UNIT . . . . . . 47VITAMIN D 2000 UNIT . . . . . . 47VITAMIN D 400 UNIT . . . . . . . 47vitamins pediatric . . . . . . . . . . 48VIVELLE . . . . . . . . . . . . . . . . . . 35VOLTAREN . . . . . . . . . . . .12, 32VOLTAREN 1% TOPICAL

GEL . . . . . . . . . . . . . . . . . . 32VOLTAREN XR . . . . . . . . .12, 32voriconazole . . . . . . . . . . . . . . 28vorinostat . . . . . . . . . . . . . . . . . . 4VOSOL HC OTIC . . . . . . . . . . 20VOSOL OTIC . . . . . . . . . . . . . . 20

VOTRIENT . . . . . . . . . . . . . . . . . 5

Wwarfarin . . . . . . . . . . . . . . . . . . . 7WELLBUTRIN . . . . . . . . . . . . . 39WELLBUTRIN SR . . . . . . . . . . 39WELLBUTRIN XL . . . . . . . . . . 39WESTCORT . . . . . . . . . . . . . . . 17WYTENSIN . . . . . . . . . . . . . . . 11

XXALATAN . . . . . . . . . . . . . . . . . 37XALKORI . . . . . . . . . . . . . . . . . . 4XANAX . . . . . . . . . . . . . . . . . . . 38XARELTO . . . . . . . . . . . . . . . . . . 7XELODA . . . . . . . . . . . . . . . . . . . 4XENAZINE . . . . . . . . . . . . . . . . 16XOLAIR . . . . . . . . . . . . . . . . . . 45XOPENEX RESPULES . . . . . . 46XULANE . . . . . . . . . . . . . . . . . . 34XYLOCAINE . . . . . . . . . . . .19, 21XYZAL . . . . . . . . . . . . . . . . . . . 20

Yyuvafem or estradiol vaginal

tablet . . . . . . . . . . . . . . . . . 35

Zzalcitabine . . . . . . . . . . . . . . . . 30zaleplon . . . . . . . . . . . . . . . . . . 40ZANAFLEX . . . . . . . . . . . . . . . 33zanamivir . . . . . . . . . . . . . . . . . 29ZANTAC . . . . . . . . . . . . . . . . . . 25ZARONTIN . . . . . . . . . . . . . . . 15ZAROXOLYN . . . . . . . . . . . . . . 10ZARXIO . . . . . . . . . . . . . . . . . . . 7ZEBETA . . . . . . . . . . . . . . . . . . . 9ZEJULA . . . . . . . . . . . . . . . . . . . 6ZELBORAF . . . . . . . . . . . . . . . . 5ZENPEP . . . . . . . . . . . . . . . . . . 26

71



ZENTANE . . . . . . . . . . . . . . . . . 16ZEPATIER . . . . . . . . . . . . . . . . 28ZERIT . . . . . . . . . . . . . . . . . . . . 30ZESTORETIC . . . . . . . . . . . . . . 8ZESTRIL . . . . . . . . . . . . . . . . . . . 8ZETIA . . . . . . . . . . . . . . . . . . . . 11ZIAC . . . . . . . . . . . . . . . . . . . . . . 9ZIAGEN . . . . . . . . . . . . . . . . . . 29zidovudine . . . . . . . . . . . . . . . . 30ZINBRYTA . . . . . . . . . . . . . . . . 14zinc . . . . . . . . . . . . . . . . . . .36, 48ziprasidone . . . . . . . . . . . . . . . 41ZITHROMAX . . . . . . . . . . . . . . 27ZOCOR. . . . . . . . . . . . . . . . . . . 11ZOFRAN . . . . . . . . . . . . . . . . . . 24ZOFRAN ODT . . . . . . . . . . . . . 24ZOHYDRO ER . . . . . . . . . . . . . 13ZOLINZA . . . . . . . . . . . . . . . . . . 4ZOLOFT . . . . . . . . . . . . . . . . . . 39zolpidem . . . . . . . . . . . . . . . . . 40ZOMACTON . . . . . . . . . . . . . . 23ZONEGRAN . . . . . . . . . . . . . . 16zonisamide . . . . . . . . . . . . . . . 16ZORTRESS . . . . . . . . . . . . . . . . 6ZOSTAVAX . . . . . . . . . . . . . . . . 51zoster vaccine live . . . . . . . . . . 51zoster vaccine recombinant

adjuvanted . . . . . . . . . . . . . 51ZOVIA 1/35 . . . . . . . . . . . . . . . 34ZOVIA 1/50 . . . . . . . . . . . . . . . 34ZOVIRAX . . . . . . . . . . . . . . . . . 29ZYDELIG . . . . . . . . . . . . . . . . . . 5ZYKADIA . . . . . . . . . . . . . . . . . . 4ZYLOPRIM . . . . . . . . . . . . . . . . 33ZYPREXA . . . . . . . . . . . . . . . . 41ZYRTEC . . . . . . . . . . . . . . . . . . 20ZYRTEC CHEWABLE

TABLET . . . . . . . . . . . . . . . 20ZYTIGA . . . . . . . . . . . . . . . . . . . 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€¦ · preferred drug list (pdl) rhode island ......

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