preferred drug list (pdl) - uhccommunityplan.com · some cases your doctor must do something before...

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

Preferred Drug List (PDL)New Jersey 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. EST.

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. You can also 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. EST.

CSNJ15MC4120674_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. hora estándar del Este.

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. hora estándar del Este.

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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 start 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 < 1-800-941-4647> 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 < 1-800-941-4647,

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 <4-65>. 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 <4-65> 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 <4-65>. 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 <66>

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 <1-800-941-4647, 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 <66>

.

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 * = Available without PA for participating Behavioral Health Prescribers [You can find information on what the symbols and abbreviations in this table mean by going to page <4-65 in the footnotes>]

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2

Table of Contents

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

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

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

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

Central Nervous System. . . . . . . . . . . . . . . . 12Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 12Amyotrophic Lateral Sclerosis (ALS). . . . . . . . . 12Analeptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 14Migraine Prophylactic Therapy . . . . . . . . . . . . . 14Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . 15Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . . 15Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 15Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . 17Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 17Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . 18Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 19Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Scabies and Pediculosis. . . . . . . . . . . . . . . . . . . 19Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . . 21Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 22

Endocrinology . . . . . . . . . . . . . . . . . . . . . . . .22Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 23Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 23Growth Stimulating Agents. . . . . . . . . . . . . . . . . 24Lipodystropy Agents . . . . . . . . . . . . . . . . . . . . . . 25Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 25Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Gastrointestinal. . . . . . . . . . . . . . . . . . . . . . .25Constipation/Laxatives . . . . . . . . . . . . . . . . . . . . 25Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Emesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Gastroesophageal Reflux Disease (Gerd)/

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

Infectious Diseases . . . . . . . . . . . . . . . . . . .28Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Antiprotozoals. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

3

Musculoskeletal . . . . . . . . . . . . . . . . . . . . . .34Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 35

OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Hormone Therapy/Menopause. . . . . . . . . . . . . 37Ovulation Stimulants . . . . . . . . . . . . . . . . . . . . . . 37Vaginal Infections. . . . . . . . . . . . . . . . . . . . . . . . . 38Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . .38Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 38Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Immunologic Agents . . . . . . . . . . . . . . . . . . . . . . 40Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Psychiatric. . . . . . . . . . . . . . . . . . . . . . . . . . . 41Alcohol Deterrents . . . . . . . . . . . . . . . . . . . . . . . . 41Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Attention Deficit Hyperactivity Disorder

(ADHD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . 42Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Medications Coverable for Participating

Behavioral Health Prescribers . . . . . . . . . . . . 43Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . . 47Psychoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . 48Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Respiratory Drugs. . . . . . . . . . . . . . . . . . . . .49Antitussives, Decongestants, Expectorants

and Combinations . . . . . . . . . . . . . . . . . . . . . . 49Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Urological . . . . . . . . . . . . . . . . . . . . . . . . . . .54Symptomatic Benign Prostatic Hypertrophy . . 54Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Vitamins and Minerals . . . . . . . . . . . . . . . . .55Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

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

OTC MEDICATIONS . . . . . . . . . . . . . . . . . . . 61Acne. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 61Cough/Cold Allergy. . . . . . . . . . . . . . . . . . . . . . . 61Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Earwax Removal Products . . . . . . . . . . . . . . . . . 62Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 62First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 63Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Motion Sickness. . . . . . . . . . . . . . . . . . . . . . . . . . 63Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Smoking Cessation Products . . . . . . . . . . . . . . 64Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . 64Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Index of Covered Drugs . . . . . . . . . . . . . . . .66

4

OTC = Over the CounterPA = Prior Authorization requiredQL = Quantity LimitST = Step Therapy

SP = Specialty Pharmacy^ Only available through manual PA process

*Available without PA for participating Behavioral Health Prescribers

± Available without PA for participating Behavioral Health Prescribers, otherwise PA required

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

Antineoplastics & Immunosuppressants

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

phosphate sodium EMCYT brand 2

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

cabozantinibCOMETRIQCABOMETYX

brand 2 PA, SP

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

everolimusAFINITORAFINITOR DISPERZ

brand 2 PA, SP

gefitinib IRESSA brand 2 PA, SP

5






ibrutinib IMBRUVICA brand 2 PA, SPidelalisib ZYDELIG brand 2 PA, SPimatinib mesylate GLEEVEC generic 1 PA, QL, SPlapatinib ditosylate TYKERB brand 2 PA, SPlenvatinib LENVIMA brand 2 PA, SPmidostaurin RYDAPT brand 2 PA, SPnilotinib TASIGNA brand 2 PA, SPpalbociclib IBRANCE brand 2 PA, SPpazopanib VOTRIENT brand 2 PA, SPponatinib ICLUSIG brand 2 PA, SPregorafenib STIVARGA brand 2 PA, SPruxolitinib JAKAFI brand 2 PA, SPsorafenib NEXAVAR brand 2 PA, SPsunitinib SUTENT brand 2 PA, SPtrametinib MEKINIST brand 2 PA, SPvandetanib CAPRELSA brand 2 PA, SPvemurafenib ZELBORAF brand 2 PA, SPMiscellaneousleucovorin LEUCOVORIN generic 1 QL, tabsmesna MESNEX brand 2 SP, tabsvenetoclax VENCLEXTA brand 2 PA, SPProteasome Inhibitorsixazomib NINLARO generic 1 PA, SPHormonal Antineoplastic AgentsAndrogen Biosynthesis Inhibitorsabiraterone ZYTIGA brand 2 PA, SPAntiandrogensbicalutamide CASODEX generic 1flutamide EULEXIN generic 1Antiestrogenstamoxifen NOLVADEX generic 1toremifene FARESTON brand 2Aromatase Inhibitorsanastrozole ARIMIDEX generic 1exemestane AROMASIN generic 1letrozole FEMARA generic 1Gonadotropin Releasing Hormone Analogleuprolide LUPRON generic 1 PA, SP

leuprolideLUPRON DEPOTLUPRON DEPOT 6-MONTHLUPRON DEPOT-PED

brand 2 PA, SP

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 22 PA, SPthalidomide THALOMID brand PA, SP, QLImmunosuppressantsAntimetabolitesazathioprine IMURAN generic 1mycophenolate mofetil CELLCEPT generic 1mycophenolate sodium MYFORTIC generic 1Calcineurin Inhibitorscyclosporine SANDIMMUNE generic 1

cyclosporine, modifiedNEORALGENGRAF

generic 1 caps, QL

tacrolimusHECORIA PROGRAF

generic 1

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

topical gel TARGRETIN brand 2 PA, SP

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

7






procarbazine MATULANE brand 2 SPrucaparib RUBRACA brand 2 PA, SPsonidegib ODOMZO brand 2 PA, SPtopotecan HYCAMTIN brand 2 PA, SPtretinoin VESANOID generic 1 caps, SPvismodegib ERIVEDGE brand 2 PA, SP

Blood Modifiers - Anticoagulants

Anticoagulantsapixaban ELIQUIS brand 2 QLbetrixaban BEVYXXA brand 2 QLedoxaban SAVAYSA brand 2 QLenoxaparin LOVENOX generic 1 PA, QL

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

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

epoetin alfaEPOGENPROCRIT

brand 2 PA, SP

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

aspirinBAYER

ECOTRINgeneric 1 OTC

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

deferasiroxEXJADEJADENU

brand 2 PA, SP

8






emicizumab-kxwh HEMLIBRA brand 2 PA, QL, SPpentoxifylline

extended-release TRENTAL generic 1

Cardiovascular Agents

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

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

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

hydrochlorothiazide LOTENSIN HCT generic 1

captopril/ hydrochlorothiazide CAPOZIDE generic 1

enalapril/ hydrochlorothiazide VASERETIC generic 1

fosinopril/ hydrochlorothiazide MONOPRIL-HCT generic 1 QL

lisinopril/ hydrochlorothiazide ZESTORETIC generic 1 QL

quinapril/ hydrochlorothiazide ACCURETIC generic 1 QL

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

9






Angiotensin II Receptor Blocker Combinationslosartan/HCTZ HYZAAR generic 1 QLsacubitril/valsartan ENTRESTO brand 2 PA, QLAntiarrhythmics and Cardiac Glycosidesamiodarone tabs CORDARONE generic 1 200 mg and 400 mgdigoxin LANOXIN generic 1disopyramide NORPACE generic 1disopyramide

extended-release NORPACE CR brand 2

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

extended-releaseQUINIDINE GLUCONATE

EXT-REL generic 1

quinidine sulfate QUINIDINE SULFATE generic 1quinidine sulfate

extended-releaseQUINIDINE SULFATE

EXT-REL generic 1

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

hydrochlorothiazide ZIAC generic 1

carvedilol COREG generic 1 QLlabetalol TRANDATE generic 1metoprolol LOPRESSOR generic 1 25, 50, 100mg tabletsmetoprolol succinate TOPROL XL generic 1propranolol INDERAL generic 1 IR onlypropranolol ER 24HR INDERAL LA generic 1 Diagnosis Required, QLpropranolol/HCTZ INDERIDE generic 1sotalol BETAPACE generic 1sotalol AF BETAPACE AF generic 1Calcium Channel BlockersDihydropyridinesamlodipine NORVASC generic 1 QLfelodipine

extended-release PLENDIL generic 1 QL

10






nicardipine CARDENE generic 1nifedipine PROCARDIA generic 1nifedipine

extended-releaseADALAT CCPROCARDIA XL

generic 1 QL

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

extended-release CARDIZEM CD generic 1 QL

diltiazem extended-release

DILACOR XR TIAZAC

generic 1 QL

diltiazem sustained-release CARDIZEM SR generic 1 QL

verapamil CALAN generic 1verapamil

extended-release CALAN SR generic 1 QL

Diureticsamiloride MIDAMOR generic 1amiloride/

hydrochlorothiazide MODURETIC generic 1

bumetanide BUMEX generic 1chlorothiazide DIURIL generic 1

chlorothiazide DIURIL ORAL SUSPENSION brand 2 QL

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

hydrochlorothiazide ALDACTAZIDE generic 1

torsemide DEMADEX generic 1triamterene/

hydrochlorothiazideDYAZIDEMAXZIDE

generic 1

11






Lipid Lowering AgentsBile Acid Resin

cholestyramineQUESTRANQUESTRAN-LIGHT

generic 1

Only the bulk products are covered (cans).

Individual packets are not covered.

Fibratesfenofibrate LOFIBRA generic 1 STgemfibrozil LOPID generic 1HMG-CoA Reductase Inhibitors and Combinationsatorvastatin LIPITOR generic 1 QLlovastatin MEVACOR generic 1 QLsimvastatin ZOCOR generic 1 QLNiacinsniacin NIACOR generic 1niacin extended-release NIASPAN generic 1Miscellaneousalirocumab PRALUENT brand 2 PA, QL, SPezetimibe ZETIA generic 1 PAomega 3 acid ethyl esters LOVAZA generic 1 PANitratesOralisosorbide dinitrate ISORDIL generic 1isosorbide dinitrate

extended-releaseISOSORBIDE

DINITRATE ER generic 1

isosorbide mononitrate ISMO generic 1isosorbide mononitrate

extended-release IMDUR generic 1

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

nitroglycerinNITREK NITRO-DUR

generic 1 transdermal, QL

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

sulfonate KAYEXALATE generic 1 susp only

12






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

Central Nervous System

Alzheimer’s Disease

donepezil ARICEPT generic 1

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

authorization.

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

prior authorization.

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

authorization.

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

authorization.

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

authorization.Amyotrophic Lateral Sclerosis (ALS)riluzole RILUTEK generic 1Analepticsarmodafinil NUVIGIL generic 1 Diagnosis Required, QL

13






AnalgesicsBarbiturate Non-Narcotic Analgesicsbutalbital/acetaminophen PHRENILIN generic 1 QLbutalbital/acetaminophen SEDAPAP generic 1 QL

butalbital/acetaminophen/caffeine

ESGIC FIORICETZEBUTAL

generic 1 QL

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

caffeine EXCEDRIN MIGRAINE generic 1 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

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

ibuprofen MOTRIN generic 1 tabs, chew tabs and susp

indomethacin INDOCIN generic 1ketoprofen ORUDIS generic 1 IR onlyketorolac tromethamine TORADOL generic 1 QLmeloxicam MOBIC generic 1 QLnabumetone RELAFEN generic 1naproxen NAPROSYN generic 1

naproxen delayed release ENTERIC COATED-NAPROSYN generic 1

oxaprozin DAYPRO generic 1piroxicam FELDENE generic 1sulindac CLINORIL generic 1Opioids - Narcotic Analgesicsbutalbital/apap/caff/cod FIORICET W/CODEINE generic 1 QL, 50-325-40-30 mgbutalbital/asa/caff/cod FIORINAL W/CODEINE generic 1 QLbutorphanol STADOL generic 1 nasal spray, QLcodeine/acetaminophen TYLENOL W/CODEINE generic 1 QLcodeine sulfate generic 1 QLfentanyl transdermal DURAGESIC generic 1 PA, QL

14






hydrocodone/ acetaminophen

LORCETLORTABLORTAB ELIXIRNORCOVICODINVICODIN ES

generic 1 QL

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

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

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

caffeineMIGERGOT

SUPPOSITORIES brand 2 QL

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

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

Migraine Prophylactic Therapyamitriptyline ELAVIL generic 1

divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1

Members ≥ 8 years of age will require prior

authorization.

15






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 SP, QLteriflunomide AUBAGIO brand 2 QL, SPMyasthenia Gravispyridostigmine MESTINON generic 1 tabspyridostigmine MESTINON brand 2 syruppyridostigmine

extended-release MESTINON TIMESPAN generic 1

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

extended-release SINEMET CR generic 1

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

extended-releaseCARBATROL TEGRETOL-XR

generic 1

clobazam ONFI brand 2 Diagnosis Required, QLclonazepam KLONOPIN generic 1 tabsdiazepam DIASTAT ACUDIAL generic 1 rectal gel, QL

divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1


authorization.

16






divalproex sodium delayed-release DEPAKOTE generic 1 Minimum age 2

ethosuximide ZARONTIN generic 1exogabine POTIGA brand 2 Age Limits Applyfelbamate FELBATOL generic 1 QL, tablets

felbamate oral susp FELBATOL ORAL SUSP generic 1

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

authorization. gabapentin NEURONTIN generic 1 caps and tabs onlylacosamide VIMPAT brand 2 Age Limits Apply, PA, QLlamotrigine 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

methsuximide CELONTIN brand 2

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

phenobarbital PHENOBARBITAL generic 1phenytoin DILANTIN INFATABS generic 1phenytoin sodium

extendedDILANTINPHENYTEK

generic 1

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

tiagabine GABITRIL generic 1 Age Limits Apply, 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 oral solution SABRIL SOLUTION brand 2 PA, SPzonisamide ZONEGRAN generic 1 QL

17






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

Dermatology

Acne VulgarisOral

isotretinoin

ABSORICAAMNESTEEMCLARAVISMYORISANZENTANE

generic 1 PA

Topicaladapalene gel DIFFERIN OTC GEL 0.1% brand 2azelaic acid FINACEA brand 2 gelbenzoyl peroxide BENZAC AC generic 1clindamycin CLEOCIN T generic 1 gelclindamycin CLEOCIN T generic 1 lotionclindamycin CLEOCIN T generic 1 solnerythromycin ERYGEL generic 1 gel 2% erythromycin T-STAT generic 1 soln

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

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

tretinoin AVITA RETIN-A

generic 1 cream, ST

Bacterial Infectionsbacitracin BACITRACIN generic 1 OTCgentamicin GENTAK generic 1

mupirocin BACTROBAN generic 1 ointment, 22 gram tube only

neomycin/polymyxin B/bacitracin NEOSPORIN generic 1 OTC

silver sulfadiazine SILVADENE generic 1

18






CorticosteroidsLow Potencyalclometasone ACLOVATE generic 1 0.05% crm/oint

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

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

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

Medium Potencybetamethasone val BETA-VAL generic 1 crm/oint/lotion 0.1%

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

fluocinolone acetonide SYNALAR generic 1 crm, oint 0.025%fluticasone propionate CUTIVATE generic 1 crm 0.05%, oint 0.005%hydrocortisone butyrate LOCOID generic 1 crm/oint/soln 0.1%hydrocortisone valerate WESTCORT generic 1 crm 0.2%mometasone furoate ELOCON generic 1 crm/oint/soln 0.1%prednicarbate DERMATOP generic 1 crm 0.1%triamcinolone acetonide KENALOG generic 1 crm/lot/oint 0.025%triamcinolone acetonide KENALOG generic 1 crm/oint/lotion 0.1%High Potencybetamethasone

augmented dip DIPROLENE generic 1 lotion 0.05%

betamethasone augmented dip DIPROLENE AF generic 1 crm 0.05%

betamethasone dipropionate generic 1 crm/lotion/oint 0.05%

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

base LIDEX E generic 1 crm 0.05%

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

augmented DIPROLENE generic 1 gel 0.05%

betamethasone dip augmented DIPROLENE generic 1 oint 0.05%

clobetasol propionate TEMOVATE generic 1 soln 0.05%halobetasol ULTRAVATE generic 1 cream

19






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

betamethasone LOTRISONE generic 1

ketoconazole NIZORAL generic 1miconazole DESENEX generic 1 2% OTCmiconazole MICATIN generic 1 OTCmiconazole MONISTAT-DERM generic 1nystatin MYCOSTATIN generic 1terbinafine LAMISIL AT generic 1 OTCtolnaftate TINACTIN generic 1 OTCPsoriasisacitretin SORIATANE generic 1 oral caps, PAcalcipotriene DOVONEX generic 1 crm/oint, STcalcipotriene DOVONEX generic 1 solncalcitriol VECTICAL generic 1 STmethoxsalen OXSORALEN-ULTRA generic 1salicylic acid SCALPICIN generic 1 liquid 3%Rosaceabrimonidine MIRVASO brand 2 PA

metronidazoleMETROCREAMMETROGELMETROLOTION

generic 1

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

butoxide shampoo RID SHAMPOO generic 1 4% OTC

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

collodion DUOFILM generic OTC

20






Miscellaneousaluminum acetate brand 2 soln/cream, OTCaluminum chloride topical

solution HYPERCARE 15% brand 2

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

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

hydrocortisone

PROCTOSOL HC CREAM 2.5%

PROCTOZONE CREAM-HC 2.5%

ANUSOL HC 2.5%

generic 1

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

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

lidocaine XYLOCAINE generic 1 jelly 2%lidocaine patch LIDODERM generic 1 Diagnosis Required, QLlidocaine/prilocaine EMLA generic 1 2.5% cream

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

pimecrolimus ELIDEL brand 2cream, QL, ST; not covered

for members less than 2 years of age

selenium sulfide SELSUN generic 1 lotion 2.5%

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

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

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

brand 2

urea 40% UREA generic 1 lotion

21






Ear, Nose & Throat

Earacetic acid VOSOL OTIC generic 1 oticacetic acid/

aluminum acetate DOMEBORO OTIC generic 1

acetic acid/ hydrocortisone VOSOL HC OTIC generic 1

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

dexamethasone CIPRODEX brand 2 Diagnosis Required, QL

neomycin/polymyxin B/hydrocortisone CORTISPORIN OTIC generic 1 otic

ofloxacin FLOXIN OTIC generic 1NoseAntihistamines - First Generation, Sedating

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

chlorpheniramine extended-release

CHLOR-TRIMETON ALLERGY generic 1 12 mg, OTC

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

cetirizine chew tab ZYRTEC CHEWABLE TABLET generic 1

OTC, Members ≥ 8 years of age will require prior

authorization.levocetirizine XYZAL generic 1 tabs

loratadineALAVERTCLARITIN

generic 1 OTC

Antihistamines - Others Antihistamine/Decongestant Combinationsazelastine ASTELIN generic 1 spray

22






Antihistamine/Decongestant Combinations - First Generationchlorpheniramine/

phenylephrine/ pyrilamine

TRIOTANN generic 1

chlorpheniramine/ pseudoephedrine ACTIFED generic 1 OTC

Antihistamine/Decongestant Combinations - Second Generationcetirizine hydrochloride/

pseudoephedrine hydrochloride 12 hours extended-release

ZYRTEC-D generic 1 5 mg-120 mg tablet

loratadine/ pseudoephedrine extended-release

ALAVERT DALAVERT ALRG

TAB/SINUSALLERGY/CONG

generic 1 OTC

Nasal Steroidsfluticasone FLONASE generic 1

triamcinolone nasal spray NASACORT ALLERGY 24 HOUR brand 2 OTC

Miscellaneous Nasal Decongestantsoxymetazoline AFRIN generic 1 OTC

phenylephrineNEO-SYNEPHRINE DIMEATAPP DRO

DECONGESgeneric 1 OTC

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

Endocrinology

Adrenal Corticosteroidscortisone acetate generic 1dexamethasone DECADRON generic 1

23






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

phosphateORAPREDPEDIAPRED

generic 1

prednisone DELTASONE generic 1Androgenstestosterone cypionate DEPO-TESTOSTERONE generic 1

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

testosterone gel topical tube, packet, and pump bottle

TESTOSTERONE 1% TOPICAL GEL generic 1 PA

Diabetes MellitusGlucose Elevating Agentsglucagon, human

recombinant GLUCAGON brand 2 QL

Insulin Combinationsinsulin glargine/lixisenatide SOLIQUA brand 2 STInsulinsinsulin aspart

protamine 70%/ insulin aspart 30%

NOVOLOG MIX 70/30 brand 2 QL, vials

insulin glargine BASAGLAR brand 2insulin glargine

300 unit/ml TOUJEO SOLOSTAR brand 2

insulin 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, vials

24






insulin lispro ADMELOG SOLOSTAR brand 2 PA, QLinsulin lispro ADMELOG VIALS brand 2 QLinsulin regular HUMULIN R brand 2 OTC, QL, vialsMonitoring - Strips and Kits/Diabetic Supplies

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

QL for insulin dependent or pregnant members:

allow testing up to 6 times per day

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

dependent members: allow twice daily testing

Oral Agentsacarbose PRECOSE generic 1alogliptin NESINA generic 1 STalogliptin/metformin KAZANO generic 1 STalogliptin/pioglitazone OSENI generic 1 STchlorpropamide DIABINESE generic 1ertugliflozin STEGLATRO brand 2 QL, STertugliflozin/metformin SEGLUROMET brand 2 QL, STglimepiride AMARYL generic 1glipizide GLUCOTROL generic 1glipizide extended-release GLUCOTROL XL generic 1glyburide MICRONASE generic 1glyburide, micronized GLYNASE generic 1metformin GLUCOPHAGE generic 1metformin ER GLUCOPHAGE ER generic 1metformin/glyburide GLUCOVANCE generic 1nateglinide STARLIX generic 1pioglitazone ACTOS generic 1 QLrepaglinide PRANDIN generic 1tolazamide TOLINASE generic 1tolbutamide TOLBUTAMIDE generic 1Miscellaneous Antidiabetic Agentsalbiglutide TANZEUM brand 2 STdulaglutide TRULICITY brand 2 STlixisenatide ADLYXIN brand 2 STpramlintide SYMLIN brand 2 PAGrowth Stimulating Agentsmecasermin INCRELEX brand 2 PA, SPsomatropin ZOMACTON brand 2 PA, SP

25






Lipodystropy Agentstesamorelin EGRIFTA brand 2 Diagnosis Required, QL, SPOsteoporosisabaloparatide inj TYMLOS brand 2 PA, SPalendronate FOSAMAX generic 1 QLcalcitonin-salmon MIACALCIN generic 1 nasal spray, QLcalcitonin-salmon FORTICAL brand 2 nasal spray, QLetidronate DIDRONEL generic 1raloxifene EVISTA generic 1Thyroid Diseaselevothyroxine LEVOXYL generic 1levothyroxine SYNTHROID generic 1liothyronine CYTOMEL generic 1liotrix THYROLAR brand 2methimazole TAPAZOLE generic 1propylthiouracil PROPYLTHIOURACIL generic 1Miscellaneousasfotase alfa STRENSIQ brand 2 PA, SPcabergoline DOSTINEX generic 1cholic acid CHOLBAM brand 2 PA, SPdesmopressin DDAVP generic 1 QLmethylergonovine METHERGINE generic 1mifepristone KORLYM brand 2 PA, SPnitisinone NITYR brand 2 Diagnosis Required, QL, SPpegvisomant SOMAVERT brand 2 PA, SPsapropterin KUVAN brand 2 Diagnosis Required, QL, SP

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

uridine VISTOGARD brand 2

Gastrointestinal

Constipation/Laxativescasanthranol-docusate

sodium generic 1 OTC

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

26






magnesium citrate soln MAGNESIUM CITRATE SOLN generic 1

peg 3350/electrolytes COLYTE generic 1peg 3350/sodium

bicarbonate/sodium chloride

TRILYTE generic 1

peg 3350/sodium bicarbonate/sodium chloride/potassium chloride

NULYTELY generic 1

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

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

ondansetronZOFRANZOFRAN ODT

generic 1 QL

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

bicarbonate brand 2 OTC

alumina/magnesia MAALOX generic 1 OTCalumina/magnesia/

simethicone MYLANTA generic 1 OTC

cimetidine TAGAMET generic 1esomeprazole NEXIUM 24HR OTC brand 2 PA

esomeprazole granules NEXIUM DELAYED RELEASE PACKET brand 2

Members ≥ 2 yearsof age will require prior

authorization.

27






famotidinePEPCIDPEPCID AC

generic 1

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

prescription.lansoprazole PREVACID generic 1

lansoprazole delayed-release PREVACID SOLUTAB generic 1

orally disintegrating tabs, Members ≥ 2 years

of age will require priorauthorization. QL

omeprazole delayed-release PRILOSEC generic 1 Capsules only, QL

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

sulcralfate CARAFATE SUSPENSION brand 2

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

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

extended-release LEVSINEX generic 1

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

extended-releaseAPRISODELZICOL

brand 2

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

delayed-release AZULFIDINE EN-TABS generic 1

Pancreatic Enzymes

pancrelipaseCREONCREON 3000 UNITZENPEP

brand 2

28






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

acidophilus/bifidus ACIDOPHILUS/BIFIDUS WAFER generic 1 OTC

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

acidophilus/pectin ACIDOPHILUS/PECTIN generic 1 caps, OTC

probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

brand 2 OTC

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

ursodiolACTIGALL URSO URSO FORTE

generic 1

Infectious Diseases

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

pyrantel pamoate PIN-X brand 2 chewable tablets, suspension

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

29






AntibacterialsAntituberculosis Agentsaminosalicyclic acid PASER brand 2cycloserine SEROMYCIN generic 1ethambutol MYAMBUTOL generic 1ethionamide TRECATOR brand 2isoniazid ISONIAZID generic 1pyrazinamide PYRAZINAMIDE generic 1rifabutin MYCOBUTIN generic 1rifampin RIFADIN generic 1rifapentine PRIFTIN brand 2Cephalosporins - First Generationcefadroxil DURICEF generic 1cephalexin KEFLEX generic 1 tabs are not coveredCephalosporins - Second Generationcefaclor CECLOR generic 1cefprozil CEFZIL generic 1cefuroxime axetil CEFTIN generic 1 tabscefuroxime axetil CEFTIN brand 2 suspensionCephalosporins - Third Generationcefdinir OMNICEF generic 1cefixime SUPRAX brand 2 400 mg caps only, QLFluoroquinolonesciprofloxacin CIPRO generic 1levofloxacin LEVAQUIN generic 1 tablets onlyofloxacin FLOXIN generic 1 tabsMacrolidesazithromycin ZITHROMAX generic 1 QLclarithromycin BIAXIN generic 1clarithromycin ER BIAXIN XL generic 1erythromycin

delayed-release ERYC generic 1

erythromycin delayed-release ERY-TAB brand 2

erythromycin ethylsuccinate E.E.S. generic 1

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

30






Penicillinsamoxicillin AMOXICILLIN CAPSULES

AND CHEWABLES generic 1 Except 500 mg and 875 mg film-coated tabs.

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

trimethoprim, DSBACTRIMBACTRIM DS

generic 1

Tetracyclines

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

minocycline MINOCIN generic 1 capsules, except 75 mgMiscellaneousvancomycin HCl VANCOCIN HCL generic 1 cap, STAntifungalsclotrimazole MYCELEX generic 1 trochesfluconazole DIFLUCAN generic 1 QLgriseofulvin microsize GRIFULVIN V generic 1griseofulvin ultramicrosize GRIS-PEG generic 1itraconazole SPORANOX generic 1 caps, PA, QLitraconazole SPORANOX brand 2 soln, PA, QLketoconazole NIZORAL generic 1nystatin MYCOSTATIN generic 1terbinafine LAMISIL generic 1 QLvoriconazole VFEND generic 1 PAAntiprotozoalsatovaquone MEPRON generic 1 PAbenznidazole BENZNIDAZOLE brand 2 PA, QLmiltefosine IMPAVIDO brand 2 PA

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

authorization.nitazoxanide tablet ALINIA brand 2 PApentamidine isethionate

for nebulization NEBUPENT brand 2

31






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

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

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

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

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

Herpes Treatmentacyclovir ZOVIRAX generic 1 caps, tabs, suspensiondocosanol ABREVA OTC CREAM brand 2valacyclovir VALTREX generic 1Influenza Treatmentamantadine SYMMETREL generic 1 except tabsoseltamivir TAMIFLU generic 1 capsules, QLrimantadine FLUMADINE generic 1zanamivir RELENZA brand 2 QLIntegrase Inhibitors:dolutegravir TIVICAY brand 2 Diagnosis Requiredraltegravir ISENTRESS brand 2 Diagnosis Required

raltegravir ISENTRESS CHEWABLE brand 2 chewable tablet, Diagnosis Required

raltegravir ISENTRESS HD brand 2 Diagnosis Required

raltegravir susp ISENTRESS SUSP brand 2

Members ≥ 2 years of age will require prior authorization. Diagnosis Required

Non-Nucleoside Reverse Transcriptase Inhibitors - Diagnosis Requireddelavirdine RESCRIPTOR brand 2efavirenz SUSTIVA brand 2etravirine INTELENCE brand 2

32






nevirapine VIRAMUNE generic 1nevirapine ER VIRAMUNE XR brand 2rilpivirine EDURANT brand 2Nucleoside Analogues Nucleoside Reverse - Transcriptase Inhibitors/and Combinations

-Diagnosis Requiredabacavir ZIAGEN generic 1abacavir/lamivudine EPZICOM generic 1abacavir/lamivudine/

zidovudine TRIZIVIR generic 1

didanosine VIDEX brand 2didanosine

delayed-release VIDEX EC generic 1

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 1zidovudine RETROVIR generic 1Nucleoside/Nucleotide Reverse - Transcriptase Inhibitor Combination - Diagnosis Requiredefavirenz/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 Inhibitor - Diagnosis Requiredtenofovir VIREAD generic 1Protease Inhibitors - Diagnosis Requiredatazanavir REYATAZ generic 1

atazanavir REYATAZ POWDER PACKET brand 2


authorization

33






darunavir PREZISTA brand 2fosamprenavir LEXIVA brand 2indinavir CRIXIVAN brand 2lopinavir/ritonavir KALETRA brand 2 tabletslopinavir/ritonavir KALETRA generic 1 solutionnelfinavir VIRACEPT brand 2ritonavir NORVIR brand 2saquinavir mesylate INVIRASE brand 2tipranavir APTIVUS brand 2Miscellaneousabacavir/dolutegravir/

lamivudine TRIUMEQ brand 2 Diagnosis Required, QL

cobicistat TYBOST brand 2 Diagnosis Required, QLcobicistat/elvitegravir/

emtricitabine/tenofovir STRIBILD brand 2 PA, QL

darunavir/cobicistat PREZCOBIX brand 2 Diagnosis Required, QLdolutegravir/rilpivirine JULUCA brand 2 Diagnosis Required, QLelvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate

GENVOYA brand 2 PA, QL

enfuvirtide FUZEON brand 2 Diagnosis Required, QLmaraviroc SELZENTRY brand 2 Diagnosis Required, 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


authorization.palivizumab SYNAGIS brand 2 PA, SP

34






paromomycin HUMATIN generic 1povidone-iodine generic 1 OTCprimaquine generic 1pyrimethamine DARAPRIM brand 2 PA, SPtrimethoprim TRIMETHOPRIM generic 1 tabs only

Musculoskeletal

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

delayed-release AZULFIDINE EN-TABS generic 1

NSAIDs and Other Analgesicsacetaminophen TYLENOL generic 1 OTC

aspirinBAYERECOTRIN

generic 1 OTC

capsaicinCAPSAGELCAPZASIN-PCASTIVA

brand 2 OTC, gel, lotion, 0.035% cream

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

celecoxib CELEBREX generic 1 PA, QL

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

35






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 QLnaproxen NAPROSYN generic 1

naproxen delayed release ENTERIC COATED-NAPROSYN generic

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

extended-release NORFLEX generic 1

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

36






OB-GYN

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

acetate DEPO-PROVERA generic 1 QL

Intravaginaletonogestrel/EE NUVARING brand 2 ring, QL

ortho diaphragmORTHO COILORTHO FLATORTHO FLEX

brand 2 QL

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

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

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

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

norgestrel/EE LO/OVRAL generic 1 0.3/30, QLMonophasic - 35 mcg Estrogenethynodiol diacetate/EE ZOVIA 1/35 generic 1 1/35, QLnorethindrone/EE BALZIVA generic 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, QL

37






norgestrel/EE OVRAL generic 1 0.5/50, QLProgestinnorethindrone ORTHO MICRONOR generic 1Transdermal

norelgestromin/EEORTHO EVRAXULANE

generic 1

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

acetate/EE/iron ESTROSTEP FE generic 1 QL

norethindrone/EE ORTHO-NOVUM 7/7/7 generic 1 QLnorethindrone/EE TRI-NORINYL generic QLnorgestimate/EE ORTHO TRI-CYCLEN generic 1 QLEndometriosisdanazol DANOCRINE generic 1Hormone Therapy/MenopauseEstrogens - Intravaginalestradiol ESTRACE CRM brand 2estrogens, conjugated PREMARIN brand 2 crmyuvafem or estradiol

vaginal tablet VAGIFEM generic 1 QL

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

medroxyprogesteronePREMPHASEPREMPRO

brand 2

Progestinsmedroxyprogesterone

acetate PROVERA generic 1

norethindrone acetate AYGESTIN generic 1progesterone micronized

cap PROMETRIUM generic 1 Diagnosis Required, QL

Ovulation Stimulantschoriogonadotropin alfa OVIDREL brand 2 Diagnosis Required, QLchorionic gonadotropin NOVAREL brand 2 Diagnosis Required, QL

38






Vaginal InfectionsOralfluconazole DIFLUCAN generic 1 QLmetronidazole FLAGYL generic 1 tabsVaginalclotrimazole GYNE-LOTRIMIN generic 1 OTCclindamycin CLEOCIN generic 1 crm

metronidazoleMETROGEL-VAGINAL METROGEL 1%

generic 1

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

bazedoxifene DUAVEE brand 2

methylergonovine METHERGINE generic 1tranexamic acid LYSTEDA generic 1 PA

Ophthalmic

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

naphazoline/glycerin CLEAR EYES REDNESS RELIEF generic 1

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

zinc sulfate VISINE-AC generic 1

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

neomycin/hc CORTISPORIN generic 1 ointment

gentamicin/prednisolone acetate PRED-G brand 2

neomycin/polymyxin B/dexamethasone MAXITROL generic 1

neomycin/polymyxin B/hydrocortisone CORTISPORIN generic 1 suspension

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

39






tobramycin/ dexamethasone TOBRADEX generic 1

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

phosphate DEXASOL generic 1 soln 0.1%

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

timolol maleate COSOPT generic 1

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

extended-release DIAMOX SEQUELS generic 1

methazolamide NEPTAZANE generic 1

40






Prostaglandinslatanoprost XALATAN generic 1 QLTopical - Parasympathomimeticspilocarpine ISOPTO CARPINE generic 1pilocarpine PILOPINE HS GEL brand 2Topical - Sympathomimeticsbrimonidine ALPHAGAN P brand 2 0.1%brimonidine ALPHAGAN P generic 1 0.15%brimonidine ALPHAGAN generic 1 0.2%Immunologic Agentslifitegrast XIIDRA brand 2 PAInfectionsBacterialbacitracin generic 1ciprofloxacin CILOXAN generic 1 solutionciprofloxacin CILOXAN brand 2 ointmenterythromycin ERYTHROMYCIN generic 1gentamicin GENTAK generic 1neomycin/bacitracin/

polymyxin NEOSPORIN generic 1 ointment

neomycin/polymyxin B/gramicidin NEOSPORIN generic 1 solution

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

ophthalmic solution CYSTARAN brand 2 Diagnosis Required, QL, SP

sodium chloride hypertonic MURO 128 generic 1 soln 5%

41






Psychiatric

Alcohol Deterrents*acamprosate CAMPRAL brand 2disulfiram ANTABUSE generic 1naltrexone REVIA generic 1Anxiety*Benzodiazepinesalprazolam 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 QLMiscellaeousbuspirone 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 ADDERALL XR IS PREFERRED)

brand 2 Age Limits Apply, QL

guanfacine ER INTUNIV generic 1 Age Limits Apply, QLlisdexamfetamine VYVANSE brand 2 Age Limits Apply, QLlisdexamfetamine

chewable tab VYVANSE CHEWABLE brand 2 Age Limits Apply, QL

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

methylphenidate extended-release

METADATE 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

42






methylphenidate HCL ER 24hr generic 1

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

54 mg tablets, Mallinckrodt and Kremers

Urban labelersBipolar Disorder*divalproex sodium

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

authorization.divalproex sodium

delayed-release DEPAKOTE generic 1 Minimum age 2

lithium carbonate LITHIUM CARBONATE generic 1lithium carbonate

extended-releaseESKALITH CR LITHOBID

generic 1

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

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

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

43






Miscellaneous 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)trazodone DESYREL generic 1 50, 100, & 150 mg onlyInsomniaBenzodiazepinesflurazepam DALMANE generic 1 QL

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

triazolam HALCION generic 1 QLNon-Benzodiazepineschloral hydrate CHLORAL HYDRATE generic 1diphenhydramine NYTOL QUICK CAPS generic 1 OTCdoxylamine succinate UNISOM generic 1 25mg, OTC, QLzaleplon SONATA generic 1 QLzolpidem AMBIEN generic 1 QLMedications Coverable for Participating Behavioral Health Prescribers±alprazolam ODT NIRAVAM generic 1alprazolam tab SR 24HR XANAX XR generic 1amphetamine extended-

release ADZENYS ER brand 2 Diagnosis Required

amphetamine sulfate EVEKEO brand 2 Age Limits Apply, Diagnosis Required

amphetamine susp extended release DYANAVEL XR brand 2 Diagnosis Required

amphetamine tab extended release dispersible

ADZENYS XR-ODT brand 2 Diagnosis Required

amphetamine/dextroamphetamine 3-bead cap ER 24hr

MYDAYIS brand 2 Diagnosis Required, QL

aripiprazole ODT ABILIFY DISCMELT brand 2 Age Limits Apply, Diagnosis Required, QL

aripiprazole oral solution ABILIFY SOLUTION brand 2 Age Limits Apply, Diagnosis Required, QL

44






asenapine maleate sublingual SAPHRIS brand 2 Diagnosis Required, QL

atomoxetine STRATTERA brand 2 Age Limits Apply,Diagnoisis Required

brexpiprazole REXULTI brand 2 Diagnosis Required , QLbuprenorphine hcl-

naloxone hcl SL film SUBOXONE brand 2 QL, 4 & 12mg

buprenorphine hcl-naloxone hcl SL tab SUBOXONE generic 1 QL

buprenorphine hcl-naloxone hcl SL ZUBSOLV brand 2 QL

buprenorphine-naloxone buccal film BUNAVAIL brand 2 QL

bupropion HCL tab SR 24HR FORFIVO XL brand 2

bupropion hcl (smoking deterrent) tab SR 12hr ZYBAN generic 1

bupropion hydrobromide APLENZIN brand 2carbamazepine

(antipsychotic) cap SR 12HR

EQUETRO brand 2

cariprazine VRAYLAR brand 2 Diagnosis Requiredchlordiazepoxide-

amitriptyline LIMBITROL DS generic 1

clomipramine ANAFRANIL generic 1clonazepam ODT KLONOPIN WAFER generic 1clonidine HCL tab

SR 12HR KAPVAY generic 1 Age Limits Apply, Diagnosis Required

clozapine CLOZARIL generic 1200 mg, Age Limits

Apply, Diagnosis Required

clozapine ODT FAZACLO generic 1 Diagnosis Requiredclozapine susp VERSACLOZ brand 2 Diagnosis Required

desvenlafaxine fumarate tab SR 24HR

DESVENLAFAXINE FUMARATE TAB SR 24HR

generic 1

desvenlafaxine succinate tab SR 24HR PRISTIQ generic 1

desvenlafaxine tab SR 24HR KHEDEZLA generic 1

45






dexmethylphenidate FOCALIN generic 1 Age Limits Apply, Diagnosis Required

dexmethylphenidate HCL cap SR 24 HR FOCALIN XR generic 1 Age Limits Apply,

Diagnosis Required

dextroamphetamineDEXEDRINEDEXTROSTAT

generic 1 Age Limits Apply, Diagnosis Required, QL

dextroamphetamine ZENZEDI brand 2 Age Limits Apply, Diagnosis Required

dextroamphetamine extended-release DEXEDRINE SPANSULE generic 1 Age Limits Apply,

Diagnosis Required, QLdextroamphetamine

sulfate oral solution PROCENTRA generic 1 Age Limits Apply, Diagnosis Required

diazepam concentrate solution DIAZEPAM INTENSOL generic 1

divalproex sodium SR 24hr DEPAKOTE ER generic 1 QL

duloxetine IRENKA generic 1escitalopram 10mg &

methylfolate-B12-B6-D thpk

PRAMLYTE brand 2

escitalopram oxalate soln LEXAPRO ORAL SOLUTION generic 1 oral solution

fluoxetine capsule PROZAC generic 1 40mgfluoxetine HCL (PMDD)

tabs SARAFEM brand 2

fluoxetine HCL cap delayed-release 90 mg PROZAC WEEKLY generic 1

fluoxetine tablet FLUOXETINE generic 1fluvoxamine maleate cap

SR 24HR LUVOX CR generic 1

haloperidol lactate oral conc HALDOL CONCENTRATE generic 1 Diagnosis Required, QL

iloperidone FANAPT brand 2 Diagnosis Required, QLimipramine pamoate TOFRANIL-PM generic 1isocarboxazid MARPLAN brand 2lamotrigine ODT LAMICTAL ODT generic 1lamotrigine SR 24hr LAMICTAL XR generic 1levomilnacipran FETZIMA brand 2lorazepam concentrate

solution LORAZEPAM INTENSOL generic 1

46






loxapine aerosol powder breath activated ADASUVE brand 2

lurasidone LATUDA brand 2 Diagnosis Required, QLmeprobamate tablet EQUANIL generic 1

methamphetamine DESOXYN generic 1 Age Limits Apply, Diagnosis Required

methylphenidate chew tabs METHYLIN generic 1 Age Limits Apply,

Diagnosis Requiredmethylphenidate

extended-release APTENSIO XR brand 2 Age Limits Apply, Diagnosis Required

methylphenidate extended-release CONCERTA generic 1 Age Limits Apply,

Diagnosis Required, QLmethylphenidate extended

release disintegrating COTEMPLA XR-ODT brand 2 Age Limits Apply, Diagnosis Required, QL

methylphenidate extended-release suspension

QUILLIVANT XR brand 2 Age Limits Apply, Diagnosis Required

methylphenidate HCL cap CR METADATE CD generic 1 Age Limits Apply,

Diagnosis Requiredmethylphenidate hcl chew

tab extended release QUILLICHEW ER brand 2 Diagnosis Required

methylphenidate patch DAYTRANA brand 2 Age Limits Apply, Diagnosis Required

mirtazapine ODT REMERON SOLTAB generic 1molindone MOBAN brand 2 Diagnosis Required, QLnaloxone hcl solution auto-

injector EVZIO brand 2

nefazodone SERZONE generic 1nicotine inhaler system NICOTROL INHALER brand 2 QLnicotine nasal spray NICOTROL NS brand 2 QLnicotine TD patch

24 HR kitNICOTINE TD PATCH

24 HR KIT brand 2

olanzapine-fluoxetine SYMBYAX generic 1 Diagnosis Requiredolanzapine INJ ZYPREXA generic 1 Diagnosis Required

olanzapine ODT ZYPREXA ZYDIS generic 1 Age Limits Apply, Diagnosis Required, QL

olanzapine pamoate for extended-release IM sus

ZYPREXA RELPREVV brand 2 Diagnosis Required, QL

47






paliperidone tab SR 24HR INVEGA generic 1 Age Limits Apply, Diagnosis Required

paroxetine HCL oral susp PAXIL brand 2paroxetine HCL tab SR

24HR PAXIL CR generic 1

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

SR 24HR SEROQUEL XR generic 1 Age Limits Apply, Diagnosis Required

risperidone ODT RISPERDAL M-TAB generic 1 Age Limits Apply, Diagnosis Required

selegiline td patch EMSAM brand 2trazodone DESYREL generic 1 300mgtrimipramine SURMONTIL brand 2valproic acid cap

delayed-release STAVZOR brand 2

venlafaxine HCL tab SR 24HR

VENLAFAXINE HCL TAB SR 24HR generic 1

vilazodone VIIBRYD brand 2vortioxetine TRINTELLIX brand 2Narcotic Antagonists*buprenorphine SUBUTEX generic 1 PA, QL*

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

naloxone NALOXONE INJ generic 1 QLnaloxone NARCAN NASAL SPRAY brand 2naltrexone REVIA generic 1

48






PsychosesAtypicals* - Diagnosis Required

aripiprazole ABILIFY TABLETS generic 1

Age Limit Applies, tablets, QL, ST, Certain daily

doses require half tablet dosing: 5 mg once daily – must be dosed as 10 mg tablet, ½ tab once daily 10 mg once daily – must be dosed as 20 mg tablet, ½ tab once

daily 15 mg once daily – must be dosed as 30 mg tablet, ½ tab once daily

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

susp ARISTADA brand 2 PA, QL

clozapine CLOZARIL generic 1 Age Limit Applies, 25mg, 50mg & 100mg only

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, 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 Cessation*nicotine NICODERM CQ generic 1 patches, QLnicotine polacrilex gum NICORETTE OTC generic 1 QLnicotine polacrilex lozenge COMMITT OTC generic 1 QLvarenicline CHANTIX brand 2 QLMiscellaneouschlorpromazine THORAZINE generic 1 Diagnosis Required*dextromethorphan/

quinidine NUEDEXTA brand 2 Diagnosis Required, QL

49






fluphenazine PROLIXIN generic 1 Diagnosis Required*fluphenazine decanoate PROLIXIN DECANOATE generic 1 Diagnosis Required*

haloperidol HALDOL generic 1 Diagnosis Required, tablets only*

haloperidol decanoate HALDOL DECANOATE generic 1 Diagnosis Required*loxapine LOXITANE generic 1 Diagnosis Required*perphenazine TRILAFON generic 1 Diagnosis Required*pimozide ORAP generic 1 Diagnosis Required*thioridazine MELLARIL generic 1 Diagnosis Required*thiothixene NAVANE generic 1 Diagnosis Required*trifluoperazine STELAZINE generic 1 Diagnosis Required*

Respiratory Drugs

Antitussives, Decongestants, Expectorants and Combinationsbenzonatate TESSALON generic 1brompheniramine &

phenylephrineDIMETAPP CLD ELX/

ALLERGY generic 1

brompheniramine/ pseudoephedrine

UNI-HIST DROPSACCUHIST DROPS

generic 1

brompheniramine/ pseudoephedrine/ dextromethorphan

BROMFED DM generic 1 syrup

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

chlorphen tan/pyrilamine tan/PE tan

TRIOTANN PEDIATRIC SUSP

R-TANNAMINEgeneric 1 susp

chlorpheniramine/ dextromethorphan

ROBITUSSIN PED LIQ CGH/COLD

ROBITUSSIN LIQ CGH/CLD

DIMETAPP SYP CGH/CLDCORICIDIN TAB

CGH/CLD

generic 1

chlorpheniramine maleate phenylephrine HCL

ED A-HIST TABLETS AND LIQUID generic 1

chlorpheniramine/ phenylephrine

RONDEC DROPSCARDEC DRO

generic 1 liquid

50






chlorpheniramine/ phenylephrine

RONDEC SYRUPCARDEC SYP

generic 1 syrup

chlorpheniramine tan/ phenylephrine tan RYNATAN PEDIATRIC SUSP generic 1 susp

chlorpheniramine/ pseudoephedrine LOHIST-D generic 1

codeine/ chlorpheniramine/pseudoephedrine

DIHISTINE DH PHENYLHIST LIQ DH

generic 1

codeine/guaifenesinGUIATUSS AC GG/CODEINE M-CLEAR WC

generic 1 QL

codeine/guaifenesin/pseudoephedrine GUIATUSS DAC generic 1

codeine/promethazine PROMETHAZINE W/CODEINE generic 1 QL

codeine/promethazine/phenylephrine

PROMETHAZINE VC W/CODEINE generic 1 QL

dextromethorphan/ brompheniramine/pseudoephedrine

BROMETANE DX generic 1

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

dextromethorphan/ guaifenesin

GG/DM CRMUCINEX DMROBITUSSIN DMTUSSIN DM

generic 1 OTC

dextromethorphan- guaifenesin

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

dextromethorphan hbrROBITUSSIN SYP MAX-STROBITUSSIN PED SYP

generic 1 syrup

dextromethorphan polistirex extended-release

DELSYM brand 2 OTC

dextromethorphan/ promethazine

PHENERGAN DMPROMETHAZINE SYP DM

generic 1

guaifenesin ROBITUSSIN generic 1 OTC

51






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

guaifenesin extended-release MUCINEX generic 1 OTC

guaifenesin/ pseudoephedrine

ROBITUSSIN PE PSE/GG

generic 1 syrup, OTC

guaifenesin/ pseudoephedrine/ dextromethorphan

ROBITUSSIN CF generic 1

guaifenesin/ pseudoephedrine extended-release

MUCINEX D generic 1 OTC

hydrocodone/homatropine

HYCODANHYDROMET SYPHYDROCODONE/

TAB HOMATROP

generic 1

loratadine & pseudoephedrine SR 24hr

CLARITIN-D generic 1

phenylephrine/ brompheniramine/ dextromethorphan

generic 1 OTC

phenylephrine/ chlorpheniramine/ dextromethorphan

RONDEC DMSTATUSS DM SYPCARDEC DM SYPMINUTUSS DR SYP

generic 1 syrup

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

52






phenylephrine/ dextromethorphan/guaifenesin

ROBITUSSIN LIQ CGH/CLD generic 1

phenylephrine/ephed/CPM w/carbetapentane

RYNATUSS PEDIATRIC SUSP generic 1 susp

phenylephrine/guaifenesin ROBITUSSIN LIQ HD/CHST generic 1

phenylephrine/ pyrilamine w/hydrocodone

CODIMAL DH generic 1 syrup

promethazine & phenylephrine

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

pseudoephedrine/ acetaminophen/ dextromethorphan

MAPAP COLD TAB generic 1

pseudoephedrine/ chlorpheniramine/ dextromethorphan

PEDIACARE LIQ MULTI-SY

ROBITUSSIN LIQ PED NGHT

generic 1

pseudoephedrine/ dextromethorphan/guaifenesin

MULTI SYMPTOM TAB COLD RLF generic 1

pseudoephedrine/ iburprofen

CHILD IBUPRO SUS COLD

IBUOROFEN TAB COLD/SIN

generic 1

pseudoephedrine tan/ dexchlorphen tan/ DM tan

TANAFED DMX SUSPENSION

TRI-FED Xgeneric 1 susp

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

tripolidine/ pseudoephedrine

TRIPROL/PSE SYPAPHEDRID TAB

generic 1

53






Asthma/COPDInhalers - Beta Agonistsalbuterol sulfate VENTOLIN HFA brand 2 QLindacaterol ARCAPTA NEOHALER brand 2olodaterol STRIVERDI RESPIMAT brand 2Inhalers - Corticosteroidsbeclomethasone QVAR brand 2 QLfluticasone furoate ARNUITY ELLIPTA brand 2 QL

mometasone ASMANEX HFA brand 2Patients 8 years and

older will require prior authorization

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

albuterol ACCUNEB generic 1

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

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

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

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

authorization, QLcromolyn INTAL generic 1 soln, QLipratropium ATROVENT generic 1 soln, QLipratropium/albuterol DUONEB generic 1 solnlevalbuterol HCl XOPENEX RESPULES generic 1 QL, STOral Agents - Beta Agonistsmetaproterenol METAPROTERENOL SYRUP generic 1terbutaline BRETHINE generic 1

54






Oral Agents - Leukotriene Modifiersmontelukast SINGULAIR generic 1 QLOral Agents - Theophyllinetheophylline THEOPHYLLINE generic 1 liquidtheophylline

extended-release THEO-24 brand 2 caps

theophylline extended-release

THEOCHRONUNIPHYL

generic 1 tabs

Urological

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

methenamine, phenyl salicylate, sodium phosphate monobasic, methylene blue

UTIRA C brand 2

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 ELMIRON brand 2 Diagnosis Required, QLpotassium citrate UROCIT-K generic 1propantheline generic 1phenazopyridine PYRIDIUM generic 1sodium citrate/citric acid BICITRA generic 1tolterodine DETROL generic 1 STtrospium SANCTURA generic 1 ST

55






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

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



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

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

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

OTCcyanocobalamin 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

56






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

TRUST NATALCARE PAK DHA brand 2

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

PRUET DHA PAK SETONET PAK brand 2

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

PRUET DHAEC PAK brand 2

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

FOLTABS PAK PLUS DHA RE OB + DHA PAK brand 2

prenatal vit w/FE bisglycinate chelate-FA

VINATE II brand 2

prenatal vit w/FE bisglycinate chelate-FA

GENTEX ADE 28-1 MG brand 2

prenatal vit w/FE b isglycinate chelate-FA VINATE AZ EX brand 2

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

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

prenatal vitamins w/folic acid

PRENATAL VITAMINS W/ FOLIC ACID

MATERNANESTABS

generic 2 QL

prenatal vit w/o vit a w/fe bisglycinate-fa brand 2 tab 32-1 mg

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 C generic 1 OTCvitamin B-6 generic 1 OTC

57






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

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

potassium citrate effervescent

K-LYTE generic 1 tabs

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

potassium chloride extended-release

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

generic 1 tabs

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

Miscellaneous

Anaphylaxis

epinephrineEPIPEN EPIPEN JR.

generic 1 QL

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

aztreonam CAYSTON brand 2 Diagnosis Required, QL, SP

dornase alfa PULMOZYME brand 2 Diagnosis Required, QL, SP

ivacaftorKALYDECOKALYDECO GRANULES

brand 2 PA, SP

lumacaftor/ivacaftor ORKAMBI brand 2 PA, SPsodium chloride for

nebulizer HYPERSALNEBUSAL

generic 1

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

58






Hereditary Angioedemac1 esterase inhibitor,

human BERINERT brand 2 PA, SP

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

icatibant FIRAZYR brand 2 PA, SPHyperphosphatemiacalcium acetate PHOSLO generic 1 667 mg tablet onlycinacalcet SENSIPAR brand 2 PAsevelamer RENVELA generic 1 STIdiopathic Pulmonary Fibrosis (IPF)nintedanib OFEV brand 2 PA, SPpirfenidone capsule ESBRIET brand 2 PA, SPImmune Thrombocytopenic Purpuraeltrombopag PROMACTA brand 2 PA, SPMedical Devicesinsulin syringes QLlancets QLspacers QLMetabolic Modifierscarglumic acid CARBAGLU brand 2 PA, SPglycerol phenylbutyrate RAVICTI brand 2 PA, SP

sodium phenylbutyrate BUPHENYL generic 1 Diagnosis Required, QL, SP

Vaccine diphtheria-tetanus tox

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

hepatitis a vaccine suspHAVRIX VAQTA

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

59






influenza virus vaccine recombinant hemagglutinin (ha)

FLUBLOK brand 2 QL

influenza virus vaccine split

AFLURIAFLUZONE SPLT

brand 2 QL

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

influenza virus vaccine split pf AFLURIA PF brand 2 QL

influenza virus vaccine split quadrivalent

FLUARIX QUADFLULAVAL QUADFLUZONE QUAD

brand 2 QL

influenza virus vaccine tiss-cult subunit FLUCELVAX brand 2 QL

influenza virus vaccine types a&b surface antigen

FLUVIRIN brand 2 QL

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

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

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

60






typhoid vaccine VIVOTIF BERNA brand 2 capsulesvaricella virus vac live for

subcutaneous VARIVAX brand 2 QL

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

recombinant adjuvanted

SHINGRIX brand 2 Age Limits Apply, QL

61





Generic Drug Name Brand Drug Name Examples

OTC MEDICATIONS

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

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

miconazole crm

tolnaftate

MICATINLOTRIMIN AFTINACTIN

vaginal productsMONISTATGYNE-LOTRIMIN

Antiviralsdocosanol ABREVA OTC CREAMAtopic Dermatitis

emollients

BETACARE CREAM AND LOTIONCETAPHIL CREAM AND LOTIONDERMAPHOR OINTMENTE-OINTMENTGLYCERIN TOPICAL

Cough/Cold Allergy

antihistamines

CHLOR-TRIMETONBENADRYLCLARITINALAVERTZYRTEC

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

loratadine/pseudoephedrineALAVERT ALRG TAB/SINUSALAVERT D ALLERGY/CONG

62






Cough/Cold

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

ROBITUSSINROBITUSSIN DMROBITUSSIN PEROBITUSSIN CFDELSYM

nasal spraysNEO-SYNEPHRINEAFRINDIMETAPP DRO DECONGES

Diabetesalcohol swabs CURITY ALCOHOL PADSglucose oral tablets

insulin (vials only) HUMULINNOVOLIN

Earwax Removal Productscarbamide peroxide DEBROXFamily Planning

condoms-male

TROJANKIMONOLIFESTYLESTRUSTEXDUREXFANTASY

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

topical antibacterialsNEOSPORINBACITRACIN

63






Gastrointestinal

antacids liquids, chew tabsMYLANTA LIQUIDMAALOX LIQUIDTUMS

antidiarrhealsIMODIUM A-DKAOPECTATE

electrolyte rehydrating soln PEDIALYTEfamotidine PEPCID AClaxative enemas FLEET ENEMA

laxativesDULCOLAXFLEET PHOSPHO-SODA

probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEX FLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

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

64






Ophthalmicsallergic conjunctivitis ALAWAYartificial tears HYPOTEARS

decongestantsVISINEMURINENAPHCON A

Pain acetaminophen tabs, liquid,

drops, suppositories, chew tabs TYLENOL

aspirin tabs, EC tabs, chew tabsBAYERECOTRIN

aspirin with buffers tabs

ibuprofen tabs, chew tabs, drops, suspADVILMOTRIN IB

Urologicaloxybutynin patch OXYTROL FOR WOMEN OTC PATCHSmoking Cessation Products

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

Vitamins/Mineralsb-complex B-COMPLEX VITAMIN TAB

calcium

CALTRATECALTRATE W/D OS-CALTUMS

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

FERGONFEOSOL

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

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

vitamins prenatal STUART PRENATAL

65






Wartssalicylic acid 17%/collodion DUOFILMMiscellaneousfluoride dental rinse PHOS-FLUR

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

Aabacavir . . . . . . . . . . . . . . .32, 33abacavir/dolutegravir/

lamivudine . . . . . . . . . . . . . 33abacavir/lamivudine . . . . . . . . 32abacavir/lamivudine/

zidovudine . . . . . . . . . . . . . 32abaloparatide inj . . . . . . . . . . . 25abemaciclib . . . . . . . . . . . . . . . . 4ABILIFY DISCMELT . . . . . . . . 43ABILIFY MAINTENA . . . . . . . . 48ABILIFY SOLUTION . . . . . . . . 43ABILIFY TABLETS . . . . . . . . . 48abiraterone . . . . . . . . . . . . . . . . . 5ABREVA OTC CREAM . . .31, 61ABSORICA . . . . . . . . . . . . . . . 17acalabrutinib . . . . . . . . . . . . . . . 4acamprosate . . . . . . . . . . . . . . 41acarbose . . . . . . . . . . . . . . . . . 24ACCUHIST DROPS . . . . . . . . 49ACCUNEB . . . . . . . . . . . . . . . . 53ACCUPRIL . . . . . . . . . . . . . . . . . 8ACCURETIC . . . . . . . . . . . . . . . 8acebutolol . . . . . . . . . . . . . . . . . 9acetaminophen

. . . . . . . . 13, 14, 34, 52, 64acetaminophen tabs, liquid,

drops, suppositories, chew tabs . . . . . . . . . . . . . . . . . . . 64

acetazolamide . . . . . . . . . . . . . 39acetazolamide

extended-release . . . . . . . 39acetic acid . . . . . . . . . . . . . . . . 21acetic acid/aluminum acetate 21acetic acid/hydrocortisone . . 21acetylcysteine . . . . . . . . . . . . . 57acidophilus . . . . . . . . . . . . . . . 28ACIDOPHILUS XTRA . . . . . . . 28acidophilus/bifidus . . . . . . . . . 28ACIDOPHILUS/BIFIDUS

WAFER . . . . . . . . . . . . . . . . 28acidophilus/citrus pectin . . . . 28acidophilus/pectin . . . . . . . . . 28acitretin . . . . . . . . . . . . . . . . . . . 19ACLOVATE . . . . . . . . . . . . . . . . 18

ACTIFED . . . . . . . . . . . . . .22, 61ACTIGALL . . . . . . . . . . . . . . . . 28ACTIMMUNE . . . . . . . . . . . . . . . 6ACTOS . . . . . . . . . . . . . . . . . . . 24ACULAR/ACULAR LS . . . . . . 39acyclovir . . . . . . . . . . . . . . . . . . 31ADACEL . . . . . . . . . . . . . . . . . . 59ADALAT CC . . . . . . . . . . . . . . . 10adalimumab . . . . . . . . . . . . . . . 34adapalene gel . . . . . . . . . .17, 61ADASUVE . . . . . . . . . . . . . . . . 46ADDERALL . . . . . . . . . . . . . . . 41ADDERALL XR . . . . . . . . . . . . 41ADEMPAS . . . . . . . . . . . . . . . . 12ADLYXIN . . . . . . . . . . . . . . . . . 24ADMELOG SOLOSTAR . . . . . 24ADMELOG VIALS . . . . . . . . . . 24ADVIL . . . . . . . . . . . . . 13, 35, 64ADZENYS ER . . . . . . . . . . . . . 43ADZENYS XR-ODT . . . . . . . . . 43afatinib . . . . . . . . . . . . . . . . . . . . 4AFINITOR . . . . . . . . . . . . . . . . . . 4AFINITOR DISPERZ . . . . . . . . . 4AFLURIA . . . . . . . . . . . . . . . . . 59AFLURIA PF . . . . . . . . . . . . . . . 59AFRIN . . . . . . . . . . . . . . . . .22, 62AGRYLIN . . . . . . . . . . . . . . . . . . 7AIRDUO RESPICLICK . . . . . . 53ALAVERT . . . . . . . . . . 21, 22, 61ALAVERT ALRG TAB/

SINUS . . . . . . . . . . . . . .22, 61ALAVERT D . . . . . . . . . . . .22, 61ALAWAY . . . . . . . . . . . . . . .38, 64ALAWAY OTC . . . . . . . . . . . . . 38albendazole . . . . . . . . . . . . . . . 28ALBENZA . . . . . . . . . . . . . . . . 28albiglutide . . . . . . . . . . . . . . . . 24albuterol . . . . . . . . . . . . . . . . . . 53albuterol sulfate . . . . . . . . . . . . 53alclometasone . . . . . . . . . . . . . 18alcohol swabs . . . . . . . . . . . . . 62ALDACTAZIDE . . . . . . . . . . . . 10ALDACTONE . . . . . . . . . . . . . . 10ALDARA . . . . . . . . . . . . . . . . . . 20ALDOMET . . . . . . . . . . . . . . . . 12ALDORIL . . . . . . . . . . . . . . . . . 12

ALECENSA . . . . . . . . . . . . . . . . 4alectinib . . . . . . . . . . . . . . . . . . . 4alendronate . . . . . . . . . . . . . . . 25ALESSE . . . . . . . . . . . . . . . . . . 36alfuzosin ER . . . . . . . . . . . . . . . 54alginic acid/sodium

bicarbonate . . . . . . . . . . . . 26ALIGN . . . . . . . . . . . . . . . . .28, 63ALINIA . . . . . . . . . . . . . . . . . . . 30ALINIA SUSPENSION . . . . . . 30alirocumab . . . . . . . . . . . . . . . . 11alitretinoin 1% gel . . . . . . . . . . . 6ALKERAN . . . . . . . . . . . . . . . . . 4allergic conjunctivitis . . . . . . . 64ALLERGY/CONG . . . . . . .22, 61allopurinol . . . . . . . . . . . . . . . . 35alogliptin . . . . . . . . . . . . . . . . . . 24alogliptin/metformin . . . . . . . . 24alogliptin/pioglitazone . . . . . . 24ALPHAGAN . . . . . . . . . . . . . . . 40ALPHAGAN P . . . . . . . . . . . . . 40alprazolam . . . . . . . . . . . . .41, 43alprazolam ODT . . . . . . . . . . . 43alprazolam tab SR 24HR . . . . 43ALTACE . . . . . . . . . . . . . . . . . . . 8altretamine . . . . . . . . . . . . . . . . . 4alumina/magnesia . . . . . . . . . 26alumina/magnesia/

simethicone . . . . . . . . . . . . 26aluminum acetate . . . . . . .20, 21aluminum chloride topical

solution . . . . . . . . . . . . . . . 20ALUNBRIG . . . . . . . . . . . . . . . . . 4amantadine . . . . . . . . . . . .15, 31AMARYL . . . . . . . . . . . . . . . . . 24AMBIEN . . . . . . . . . . . . . . . . . . 43ambrisentan . . . . . . . . . . . . . . . 12AMERGE . . . . . . . . . . . . . . . . . 14AMICAR . . . . . . . . . . . . . . . . . . . 7amiloride . . . . . . . . . . . . . . . . . 10amiloride/

hydrochlorothiazide . . . . . 10aminocaproic acid . . . . . . . . . . 7aminosalicyclic acid . . . . . . . . 29amiodarone tabs . . . . . . . . . . . . 9

Index of Covered Drugs



amitriptyline . . . . . . . . . . . .14, 42amitriptyline/perphenazine . . 42amlodipine . . . . . . . . . . . . . . . . . 9ammonium lactate . . . . . . . . . 20AMNESTEEM . . . . . . . . . . . . . 17amoxapine . . . . . . . . . . . . . . . . 42amoxicillin . . . . . . . . . . . . . . . . 30AMOXICILLIN CAPSULES AND

CHEWABLES . . . . . . . . . . 30amoxicillin/clavulanate . . . . . . 30AMOXIL SUSP. . . . . . . . . . . . . 30amphetamine

extended-release . . . . . . . 43amphetamine sulfate . . . . . . . 43amphetamine susp extended

release . . . . . . . . . . . . . . . . 43amphetamine tab extended

release dispersible . . . . . . 43amphetamine/

dextroamphetamine 3-bead cap ER 24hr . . . . . . . . . . . 43

amphetamine/dextroamphetamine mixed salts . . . . . . . . . . . . . . . . . . 41

amphetamine/dextroamphetamine mixed salts extended-release . . . 41

ampicillin . . . . . . . . . . . . . . . . . 30ANAFRANIL . . . . . . . . . . . . . . . 44anagrelide . . . . . . . . . . . . . . . . . 7anakinra . . . . . . . . . . . . . . . . . . 34anastrozole. . . . . . . . . . . . . . . . . 5ANTABUSE . . . . . . . . . . . . . . . 41antacids liquids, chew tabs . . 63antidiarrheals . . . . . . . . . . . . . . 63antihistamines . . . . . . . . . .21, 61antitussives . . . . . . . . . 3, 49, 62ANTIVERT . . . . . . . . . . . . . . . . 26ANUSOL HC 2.5% . . . . . . . . . 20APHEDRID TAB . . . . . . . . . . . 52apixaban . . . . . . . . . . . . . . . . . . 7APLENZIN . . . . . . . . . . . . . . . . 44apremilast . . . . . . . . . . . . . . . . 34aprepitant . . . . . . . . . . . . . . . . . 26APRESOLINE . . . . . . . . . . . . . 12APRISO . . . . . . . . . . . . . . . . . . 27

APTENSIO XR . . . . . . . . . . . . . 46APTIVUS . . . . . . . . . . . . . . . . . 33ARALEN . . . . . . . . . . . . . . . . . . 33ARANESP . . . . . . . . . . . . . . . . . 7ARAVA . . . . . . . . . . . . . . . . . . . 34ARCAPTA NEOHALER . . . . . 53ARICEPT . . . . . . . . . . . . . . . . . 12ARIMIDEX . . . . . . . . . . . . . . . . . 5aripiprazole . . . . . . . . . . . .43, 48aripiprazole ER injection . . . . 48aripiprazole lauroxil IM

ER susp . . . . . . . . . . . . . . . 48aripiprazole ODT . . . . . . . . . . . 43aripiprazole oral solution . . . . 43ARISTADA . . . . . . . . . . . . . . . . 48armodafinil . . . . . . . . . . . . . . . . 12ARNUITY ELLIPTA . . . . . . . . . 53AROMASIN . . . . . . . . . . . . . . . . 5ARTANE . . . . . . . . . . . . . . . . . . 15artificial tears . . . . . . . . . . . . . . 64asenapine maleate

sublingual . . . . . . . . . . . . . 44asfotase alfa . . . . . . . . . . . . . . . 25ASMANEX HFA . . . . . . . . . . . . 53aspirin . . . . . . . .7, 13, 14, 34, 64aspirin tabs, EC tabs,

chew tabs . . . . . . . . . . . . . 64aspirin with buffers tabs . . . . . 64aspirin/acetaminophen/

caffeine . . . . . . . . . . . . . . . 13ASTELIN. . . . . . . . . . . . . . . . . . 21ATABEX PRENATAL . . . . . . . . 56ATARAX . . . . . . . . . . . . . . . . . . 21atazanavir . . . . . . . . . . . . . . . . . 32atenolol . . . . . . . . . . . . . . . . . . . . 9atenolol/chlorthalidone . . . . . . 9ATIVAN . . . . . . . . . . . . . . . . . . . 41atomoxetine . . . . . . . . . . . . . . . 44atorvastatin . . . . . . . . . . . . . . . 11atovaquone . . . . . . . . . . . . . . . 30ATRIPLA . . . . . . . . . . . . . . . . . . 32atropine . . . . . . . . . . . 26, 28, 39atropine sulfate . . . . . . . . . . . . 28ATROVENT . . . . . . . . . . . .22, 53ATROVENT HFA . . . . . . . . . . . 53ATROVENT NASAL SPRAY . 22

AUBAGIO . . . . . . . . . . . . . . . . . 15AUGMENTIN . . . . . . . . . . . . . . 30auranofin . . . . . . . . . . . . . . . . . 34AVITA . . . . . . . . . . . . . . . . . . . . 17axitinib . . . . . . . . . . . . . . . . . . . . 4AYGESTIN . . . . . . . . . . . . . . . . 37azathioprine . . . . . . . . . . . . . 6, 34azelaic acid . . . . . . . . . . . . . . . 17azelastine . . . . . . . . . . . . . .21, 38azithromycin . . . . . . . . . . . . . . 29aztreonam . . . . . . . . . . . . . . . . 57AZULFIDINE . . . . . . . . . . .27, 34AZULFIDINE EN-TABS . . .27, 34

Bb-complex . . . . . . . . . . . . .55, 64B-complex vitamin tab . . .55, 64BACID . . . . . . . . . . . . . . . . .28, 63bacitracin . . . . . . . 17, 38, 40, 62bacitracin/polymyxin/

neomycin/hc . . . . . . . . . . . 38baclofen . . . . . . . . . . . . . . . . . . 35BACTRIM . . . . . . . . . . . . . . . . . 30BACTRIM DS . . . . . . . . . . . . . . 30BACTROBAN . . . . . . . . . . . . . 17balsalazide . . . . . . . . . . . . . . . . 27BALZIVA . . . . . . . . . . . . . . . . . . 36BANZEL . . . . . . . . . . . . . . . . . . 16BARACLUDE . . . . . . . . . . . . . . 31BASAGLAR . . . . . . . . . . . . . . . 23BAYER . . . . . . . . . . . . . 7, 34, 64becaplermin gel . . . . . . . . . . . 20beclomethasone . . . . . . . . . . . 53bedaquiline . . . . . . . . . . . . . . . 33BENADRYL . . . . . . . . . . . .21, 61benazepril . . . . . . . . . . . . . . . . . 8benazepril/

hydrochlorothiazide . . . . . . 8BENTYL . . . . . . . . . . . . . . . . . . 27BENZAC AC . . . . . . . . . . . . . . 17benznidazole . . . . . . . . . . . . . . 30benzocaine/antipyrine . . . . . . 21benzonatate . . . . . . . . . . . . . . . 49BENZOTIC . . . . . . . . . . . . . . . . 21benzoyl peroxide . . . . . . . .17, 61

68


Index of Covered Drugsbenzoyl peroxide crm, gel,

lotion . . . . . . . . . . . . . . . . . . 61benztropine . . . . . . . . . . . . . . . 15BERINERT . . . . . . . . . . . . . . . . 58BETA-VAL . . . . . . . . . . . . . . . . 18BETACARE CREAM AND

LOTION . . . . . . . . . . . . . . . 61BETAGAN . . . . . . . . . . . . . . . . 39betamethasone augmented

dip . . . . . . . . . . . . . . . . . . . . 18betamethasone dip

augmented . . . . . . . . . . . . 18betamethasone dipropionate 18betamethasone val . . . . . . . . . 18BETAPACE . . . . . . . . . . . . . . . . 9BETAPACE AF . . . . . . . . . . . . . . 9betaxolol . . . . . . . . . . . . . . . . . . . 9bethanechol . . . . . . . . . . . . . . . 54BETHKIS . . . . . . . . . . . . . . . . . 57betrixaban . . . . . . . . . . . . . . . . . 7BEVYXXA . . . . . . . . . . . . . . . . . 7bexarotene caps and

topical gel . . . . . . . . . . . . . . 6BIAXIN . . . . . . . . . . . . . . . . . . . 29BIAXIN XL . . . . . . . . . . . . . . . . 29bicalutamide . . . . . . . . . . . . . . . 5BICITRA . . . . . . . . . . . . . . . . . . 54BILTRICIDE . . . . . . . . . . . . . . . 28BIO-D DRO-MULSION . . . . . . 55BIO-D-MULSIO DRO FORTE 55BIOGAIA . . . . . . . . . . . . . . .28, 63bisoprolol . . . . . . . . . . . . . . . . . . 9bisoprolol/

hydrochlorothiazide . . . . . . 9BLEPH-10 . . . . . . . . . . . . . . . . 40BONINE . . . . . . . . . . . . . . . . . . 63BOOSTRIX . . . . . . . . . . . . . . . . 59bosentan . . . . . . . . . . . . . . . . . 12BOSULIF . . . . . . . . . . . . . . . . . . 4bosutinib . . . . . . . . . . . . . . . . . . 4BREO ELLIPTA . . . . . . . . . . . . 53BRETHINE . . . . . . . . . . . . . . . . 53brexpiprazole . . . . . . . . . . . . . . 44brigatinib . . . . . . . . . . . . . . . . . . 4BRILINTA . . . . . . . . . . . . . . . . . . 7brimonidine . . . . . . . . . . . .19, 40

BROMETANE DX . . . . . . . . . . 50BROMFED DM . . . . . . . . . . . . 49brompheniramine &

phenylephrine . . . . . . . . . . 49brompheniramine/

pseudoephedrine 49, 50, 61brompheniramine/

pseudoephedrine/dextromethorphan . . . . . . 49

budesonide . . . . . . . . . . . .27, 53bumetanide . . . . . . . . . . . . . . . 10BUMEX . . . . . . . . . . . . . . . . . . . 10BUNAVAIL . . . . . . . . . . . . . . . . 44BUPHENYL . . . . . . . . . . . . . . . 58buprenorphine . . . . . . . . .44, 47buprenorphine hcl-naloxone hcl

SL . . . . . . . . . . . . . . . . . . . . 44buprenorphine hcl-naloxone hcl

SL film . . . . . . . . . . . . . . . . 44buprenorphine hcl-naloxone hcl

SL tab . . . . . . . . . . . . . . . . . 44buprenorphine-naloxone buccal

film . . . . . . . . . . . . . . . . . . . 44buprenorphine/naloxone . . . . 47bupropion . . . . . . . . . . . . .43, 44bupropion extended-release . 43bupropion hcl (smoking

deterrent) tab SR 12hr . . . 44bupropion HCL tab SR

24HR . . . . . . . . . . . . . . . . . 44bupropion hydrobromide . . . 44Burow’s soln, wet dressings . 62BUSPAR . . . . . . . . . . . . . . . . . . 41buspirone . . . . . . . . . . . . . . . . . 41busulfan . . . . . . . . . . . . . . . . . . . 4butalbital/acetaminophen . . . 13butalbital/acetaminophen/

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

Cc1 esterase inhibitor, human . 58cabergoline . . . . . . . . . . . . . . . 25

CABOMETYX . . . . . . . . . . . . . . 4cabozantinib . . . . . . . . . . . . . . . 4CAFERGOT . . . . . . . . . . . . . . . 14calamine . . . . . . . . . . . . . . . . . . 20CALAN . . . . . . . . . . . . . . . .10, 15CALAN SR . . . . . . . . . . . . . . . . 10calcipotriene . . . . . . . . . . . . . . 19calcitonin-salmon . . . . . . . . . . 25calcitriol . . . . . . . . . . . . . . .19, 55calcitriol oral soln . . . . . . . . . . 55calcium . . . . 2, 9, 25, 55, 58, 64calcium acetate . . . . . . . . . . . . 58calcium carb-vit D

w/ minerals . . . . . . . . . . . . 55CALQUENCE . . . . . . . . . . . . . . 4CALTRATE . . . . . . . . . . . . .55, 64CALTRATE W/D . . . . . . . .55, 64CAMPRAL . . . . . . . . . . . . . . . . 41canakinumab . . . . . . . . . . . . . 34CANASA. . . . . . . . . . . . . . . . . . 27capecitabine . . . . . . . . . . . . . . . 4CAPOTEN . . . . . . . . . . . . . . . . . 8CAPOZIDE . . . . . . . . . . . . . . . . . 8CAPRELSA . . . . . . . . . . . . . . . . 5CAPSAGEL . . . . . . . . . . . . . . . 34capsaicin . . . . . . . . . . . . . . . . . 34captopril . . . . . . . . . . . . . . . . . . . 8captopril/hydrochlorothiazide . 8CAPZASIN-P . . . . . . . . . . . . . . 34CARAFATE . . . . . . . . . . . . . . . . 27CARAFATE SUSPENSION . . 27CARBAGLU . . . . . . . . . . . . . . . 58carbamazepine . . . . . . . . .15, 44carbamazepine (antipsychotic)

cap SR 12HR . . . . . . . . . . 44carbamazepine extended-

release . . . . . . . . . . . . . . . . 15carbamide peroxide . . . . .21, 62CARBATROL . . . . . . . . . . . . . . 15carbidopa/levodopa . . . . . . . . 15carbidopa/levodopa

extended-release . . . . . . . 15CARDEC DM DRO . . . . . . . . . 51CARDEC DM SYP . . . . . . . . . 51CARDEC DRO . . . . . . . . . . . . . 49CARDEC SYP . . . . . . . . . . . . . 50

69



CARDENE . . . . . . . . . . . . . . . . 10CARDIZEM . . . . . . . . . . . . . . . 10CARDIZEM CD . . . . . . . . . . . . 10CARDIZEM SR . . . . . . . . . . . . 10CARDURA . . . . . . . . . . . . . . 8, 54carglumic acid . . . . . . . . . . . . . 58cariprazine . . . . . . . . . . . . . . . . 44carteolol . . . . . . . . . . . . . . . . . . 39carvedilol . . . . . . . . . . . . . . . . . . 9casanthranol-docusate

sodium . . . . . . . . . . . . . . . . 25CASODEX . . . . . . . . . . . . . . . . . 5CASTIVA . . . . . . . . . . . . . . . . . 34CATAFLAM . . . . . . . . . . . .13, 35CATAPRES . . . . . . . . . . . . . . . . . 8CAYSTON . . . . . . . . . . . . . . . . 57CECLOR . . . . . . . . . . . . . . . . . 29cefaclor . . . . . . . . . . . . . . . . . . . 29cefadroxil . . . . . . . . . . . . . . . . . 29cefdinir . . . . . . . . . . . . . . . . . . . 29cefixime . . . . . . . . . . . . . . . . . . 29cefprozil . . . . . . . . . . . . . . . . . . 29CEFTIN . . . . . . . . . . . . . . . . . . . 29cefuroxime axetil . . . . . . . . . . . 29CEFZIL . . . . . . . . . . . . . . . . . . . 29CELEBREX . . . . . . . . . . . . . . . 34celecoxib . . . . . . . . . . . . . . . . . 34CELEXA . . . . . . . . . . . . . . . . . . 42CELLCEPT . . . . . . . . . . . . . . . . . 6CELONTIN . . . . . . . . . . . . . . . . 16CENTRUM . . . . . . . . . . . . . . . . 55cephalexin . . . . . . . . . . . . . . . . 29ceritinib . . . . . . . . . . . . . . . . . . . . 4certolizumab pegol . . . . . . . . . 34CETAPHIL CREAM AND

LOTION . . . . . . . . . . . . . . . 61cetirizine . . . . . . . . . . . 21, 22, 61cetirizine chew tab . . . . . . . . . 21cetirizine hydrochloride/

pseudoephedrine hydrochloride 12 hours extended-release . . . . . . . 22

cetirizine/pseudoephedrine OTC . . . . . . . . . . . . . . . . . . 61

CETYLEV . . . . . . . . . . . . . . . . . 57CHANTIX . . . . . . . . . . . . . . . . . 48

CHEMET . . . . . . . . . . . . . . . . . 57CHILD IBUPRO SUS COLD . 52CHLOR-TRIMETON . . . . .21, 61CHLOR-TRIMETON

ALLERGY . . . . . . . . . . . . . 21CHLOR-TRIMETON SYRUP . 21chloral hydrate . . . . . . . . . . . . . 43chlorambucil . . . . . . . . . . . . . . . 4chlordiazepoxide. . . . . . . . . . . 41chlordiazepoxide-

amitriptyline . . . . . . . . . . . 44chlorhexidine gluconate. . . . . 22chloroquine phosphate . . . . . 33chlorothiazide . . . . . . . . . . . . . 10chlorphen tan/carbetapentane

tan . . . . . . . . . . . . . . . . . . . . 49chlorphen tan/pyrilamine tan/

PE tan . . . . . . . . . . . . . . . . . 49chlorpheniramine extended-

release . . . . . . . . . . . . . . . . 21chlorpheniramine

maleate . . . . . . . . . . . .21, 49chlorpheniramine maleate

phenylephrine HCL . . . . . 49chlorpheniramine tan/

phenylephrine tan. . . . . . . 50chlorpheniramine/

dextromethorphan . . . . . . . . 49, 51, 52

chlorpheniramine/phenylephrine . . . 22, 49, 50

chlorpheniramine/phenylephrine/ pyrilamine . . . . . . . . . . . . . 22

chlorpheniramine/pseudoephedrine 22, 50, 61

chlorpromazine . . . . . . . . . . . . 48chlorpropamide. . . . . . . . . . . . 24chlorthalidone . . . . . . . . . . . 9, 10chlorzoxazone . . . . . . . . . . . . . 35cholbam . . . . . . . . . . . . . . . . . . 25cholecalciferol . . . . . . . . . . . . . 55cholestyramine . . . . . . . . . . . . 11cholic acid . . . . . . . . . . . . . . . . 25choriogonadotropin alfa . . . . . 37chorionic gonadotropin . . . . . 37

ciclopirox . . . . . . . . . . . . . . . . . 19cilostazol . . . . . . . . . . . . . . . . . . 7CILOXAN . . . . . . . . . . . . . . . . . 40CIMDUO . . . . . . . . . . . . . . . . . . 32cimetidine . . . . . . . . . . . . . . . . 26CIMZIA . . . . . . . . . . . . . . . . . . . 34cinacalcet . . . . . . . . . . . . . . . . . 58CIPRO . . . . . . . . . . . . . . . . . . . 29CIPRODEX . . . . . . . . . . . . . . . . 21ciprofloxacin . . . . . . . 21, 29, 40ciprofloxacin/

dexamethasone . . . . . . . . 21citalopram . . . . . . . . . . . . . . . . 42CLARAVIS . . . . . . . . . . . . . . . . 17clarithromycin . . . . . . . . . . . . . 29clarithromycin ER . . . . . . . . . . 29CLARITIN . . . . . . . . . . . . . .21, 61CLARITIN-D . . . . . . . . . . . . . . . 51CLEAR EYES REDNESS

RELIEF . . . . . . . . . . . . . . . . 38CLEARASIL . . . . . . . . . . . . . . . 61clemastine . . . . . . . . . . . . . . . . 21CLEOCIN . . . . . . . . . . 17, 33, 38CLEOCIN T . . . . . . . . . . . . . . . 17CLIMARA . . . . . . . . . . . . . . . . . 37clindamycin . . . . . . . . 17, 33, 38CLINORIL . . . . . . . . . . . . . .13, 35clobazam . . . . . . . . . . . . . . . . . 15clobetasol propionate. . . . . . . 18clomipramine. . . . . . . . . . . . . . 44clonazepam . . . . . . . . 15, 41, 44clonazepam ODT . . . . . . . . . . 44clonidine. . . . . . . . . . . . . . . . 8, 44clonidine HCL tab SR 12HR . 44clopidogrel . . . . . . . . . . . . . . . . . 7clorazepate . . . . . . . . . . . . . . . 41clotrimazole . . . . . 19, 30, 38, 61clotrimazole with

betamethasone . . . . . . . . . 19clozapine . . . . . . . . . . . . . .44, 48clozapine ODT . . . . . . . . . . . . . 44clozapine susp . . . . . . . . . . . . 44CLOZARIL . . . . . . . . . . . . .44, 48cobicistat . . . . . . . . . . . . . . . . . 33cobicistat/elvitegravir/

emtricitabine/tenofovir . . . 33

70


Index of Covered Drugscobimetinib . . . . . . . . . . . . . . . . 4codeine sulfate . . . . . . . . . . . . 13codeine/acetaminophen . . . . 13codeine/chlorpheniramine/

pseudoephedrine . . . . . . . 50codeine/guaifenesin. . . . . . . . 50codeine/guaifenesin/

pseudoephedrine . . . . . . . 50codeine/promethazine. . . . . . 50codeine/promethazine/

phenylephrine . . . . . . . . . . 50CODIMAL DH . . . . . . . . . . . . . 52COGENTIN . . . . . . . . . . . . . . . 15COLACE . . . . . . . . . . . . . .25, 63COLAZAL . . . . . . . . . . . . . . . . 27colchicine . . . . . . . . . . . . . . . . . 35collagenase . . . . . . . . . . . . . . . 20COLLOIDAL OATMEAL

BATHS . . . . . . . . . . . . . . . . 62COLOCORT. . . . . . . . . . . . . . . 27COLYTE . . . . . . . . . . . . . . . . . . 26COMBIVENT RESPIMAT . . . . 53COMBIVIR . . . . . . . . . . . . . . . . 32COMETRIQ . . . . . . . . . . . . . . . . 4COMMIT LOZENGES . . . . . . . 64COMMITT OTC . . . . . . . . . . . . 48COMPAZINE . . . . . . . . . . . . . . 26COMPLERA . . . . . . . . . . . . . . 32COMPLETE NATALCARE PAK

DHA . . . . . . . . . . . . . . . . . . 55COMTAN . . . . . . . . . . . . . . . . . 15CONCERTA . . . . . . . . . . . . . . . 46condoms-male . . . . . . . . . . . . 62CONDYLOX SOL . . . . . . . . . . 19conjugated estrogen/

bazedoxifene . . . . . . . . . . . 38contraceptive foam . . . . . . . . . 62contraceptive gel . . . . . . . . . . . 62COPAXONE . . . . . . . . . . . . . . . 15CORDARONE . . . . . . . . . . . . . . 9COREG . . . . . . . . . . . . . . . . . . . 9CORICIDIN TAB CGH/CLD . . 49CORTAID . . . . . . . . . . . . . . . . . 62CORTEF . . . . . . . . . . . . . . . . . . 23cortisone acetate . . . . . . . . . . 22CORTISPORIN . . . . . . . . .21, 38

CORTISPORIN OTIC . . . . . . . 21CORTIZONE . . . . . . . . . . . . . . 18CORTIZONE-10 INTENSIVE

HEALING . . . . . . . . . . . . . . 18COSENTYX . . . . . . . . . . . . . . . 34COSOPT . . . . . . . . . . . . . . . . . 39COTELLIC . . . . . . . . . . . . . . . . . 4COTEMPLA XR-ODT . . . . . . . 46COUMADIN . . . . . . . . . . . . . . . . 7COZAAR . . . . . . . . . . . . . . . . . . 8CREON . . . . . . . . . . . . . . . . . . . 27CREON 3000 UNIT . . . . . . . . 27crisaborole . . . . . . . . . . . . . . . . 20CRIXIVAN . . . . . . . . . . . . . . . . . 33crizotinib . . . . . . . . . . . . . . . . . . . 4crofelemer . . . . . . . . . . . . . . . . 26CROLOM . . . . . . . . . . . . . . . . . 38cromolyn . . . . . . . . . . 22, 38, 53cromolyn sodium . . . . . . .22, 38crotamiton . . . . . . . . . . . . . . . . 19CULTURELLE . . . . . . . . . .28, 63CURITY ALCOHOL PADS . . . 62CUTIVATE . . . . . . . . . . . . . . . . 18cyanocobalamin . . . . . . . . . . . 55CYCLESSA . . . . . . . . . . . . . . . 37cyclobenzaprine . . . . . . . . . . . 35CYCLOGYL . . . . . . . . . . . . . . . 39cyclopentolate . . . . . . . . . . . . . 39cyclophosphamide . . . . . . . . . . 4cycloserine . . . . . . . . . . . . . . . . 29cyclosporine . . . . . . . . . . . . . . . 6cyclosporine, modified . . . . . . . 6CYMBALTA . . . . . . . . . . . . . . . 42cyproheptadine . . . . . . . . . . . . 21CYSTAGON . . . . . . . . . . . . . . . . 6CYSTARAN . . . . . . . . . . . . . . . 40cysteamine 0.44% ophthalmic

solution . . . . . . . . . . . . . . . 40cysteamine bitartrate . . . . . . . . 6CYTOMEL . . . . . . . . . . . . . . . . 25CYTOTEC . . . . . . . . . . . . . . . . 28CYTOVENE . . . . . . . . . . . . . . . 31CYTOXAN . . . . . . . . . . . . . . . . . 4

DD3-50 CAP . . . . . . . . . . . . . . . . 55

D.H.E. 45 . . . . . . . . . . . . . . . . . 14dabrafenib . . . . . . . . . . . . . . . . . 4daclizumab . . . . . . . . . . . . . . . 15DALMANE . . . . . . . . . . . . . . . . 43danazol . . . . . . . . . . . . . . . . . . . 37DANOCRINE . . . . . . . . . . . . . . 37DANTRIUM . . . . . . . . . . . . . . . 35dantrolene . . . . . . . . . . . . . . . . 35dapsone . . . . . . . . . . . . . . . . . . 33DARAPRIM . . . . . . . . . . . . . . . 34darbepoetin alfa . . . . . . . . . . . . 7darunavir . . . . . . . . . . . . . . . . . 33darunavir/cobicistat . . . . . . . . 33dasatinib . . . . . . . . . . . . . . . . . . . 4DAYPRO . . . . . . . . . . . . . . .13, 35DAYTRANA . . . . . . . . . . . . . . . 46DDAVP . . . . . . . . . . . . . . . . . . . 25DEBROX . . . . . . . . . . . . . .21, 62DECADRON . . . . . . . . . . . . . . 22decongestants . . . 3, 22, 49, 64deferasirox . . . . . . . . . . . . . . . . . 7DELATESTRYL . . . . . . . . . . . . 23delavirdine . . . . . . . . . . . . . . . . 31DELFEN . . . . . . . . . . . . . . . . . . 62DELSYM . . . . . . . . . . . . . . .50, 62DELTASONE . . . . . . . . . . . . . . 23DELZICOL . . . . . . . . . . . . . . . . 27DEMADEX . . . . . . . . . . . . . . . . 10DEMEROL . . . . . . . . . . . . . . . . 14DEPAKENE . . . . . . . . . . . . . . . 16DEPAKOTE . . . . . 14-16, 42, 45DEPAKOTE ER . . . . . . . . . . . . 45DEPAKOTE

SPRINKLE . . . . . . 14, 15, 42DEPEN TITRATABLE . . . . . . . 34DEPO-PROVERA . . . . . . . . . . 36DEPO-TESTOSTERONE . . . . 23DERMA-SMOOTHE OIL/FS . 18DERMAPHOR OINTMENT . . 61dermatological baths . . . . . . . 62DERMATOP . . . . . . . . . . . . . . . 18DESCOVY . . . . . . . . . . . . . . . . 32DESENEX . . . . . . . . . . . . . . . . 19desipramine . . . . . . . . . . . . . . . 42desmopressin . . . . . . . . . . . . . 25desogestrel/EE . . . . . . . . .36, 37

71



DESOXYN . . . . . . . . . . . . . . . . 46desvenlafaxine fumarate tab

SR 24HR . . . . . . . . . . . . . . 44desvenlafaxine succinate tab

SR 24HR . . . . . . . . . . . . . . 44desvenlafaxine tab SR

24HR . . . . . . . . . . . . . . . . . 44DESYREL . . . . . . . . . . . . . .43, 47DETROL . . . . . . . . . . . . . . . . . . 54dexamethasone . 21, 22, 38, 39dexamethasone sodium

phosphate . . . . . . . . . . . . . 39DEXASOL . . . . . . . . . . . . . . . . 39DEXEDRINE . . . . . . . . . . . . . . 45DEXEDRINE SPANSULE . . . . 45dexmethylphenidate . . . . . . . . 45dexmethylphenidate HCL cap

SR 24 HR . . . . . . . . . . . . . 45dextroamphetamine . 41, 43, 45dextroamphetamine

extended-release . . . . . . . 45dextroamphetamine sulfate oral

solution . . . . . . . . . . . . . . . 45dextromethorphan hbr . . . . . . 50dextromethorphan polistirex

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

guaifenesin . . . . . . . . . . . . 50dextromethorphan/

brompheniramine/pseudoephedrine . . . . . . . 50

dextromethorphan/ guaifenesin . . . . . . . . .50, 52

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

dextromethorphan/quinidine 48DEXTROSTAT . . . . . . . . . . . . . 45DIABINESE . . . . . . . . . . . . . . . 24DIAMOX SEQUELS . . . . . . . . 39DIASTAT ACUDIAL . . . . . . . . . 15diazepam . . . . . . . 15, 35, 41, 45diazepam concentrate

solution . . . . . . . . . . . . . . . 45DIAZEPAM INTENSOL . . . . . 45diclofenac 1% gel . . . . . . . . . . 34diclofenac potassium . . . .13, 35

diclofenac sodium . . 13, 35, 39diclofenac sodium delayed-

release . . . . . . . . . . . . .13, 35diclofenac sodium extended-

release . . . . . . . . . . . . .13, 35dicloxacillin . . . . . . . . . . . . . . . 30dicyclomine . . . . . . . . . . . . . . . 27didanosine . . . . . . . . . . . . . . . . 32didanosine delayed-release . . 32DIDRONEL. . . . . . . . . . . . . . . . 25DIFFERIN OTC GEL 0.1% 17, 61DIFICID . . . . . . . . . . . . . . . . . . . 29DIFLUCAN . . . . . . . . . . . . .30, 38DIGESTIVE PROBIOTIC .28, 63digoxin . . . . . . . . . . . . . . . . . . . . 9DIHISTINE DH . . . . . . . . . . . . . 50DIHYDRO-PE SYP . . . . . . . . . 51dihydroergotamine . . . . . . . . . 14DILACOR XR . . . . . . . . . . . . . . 10DILANTIN . . . . . . . . . . . . . . . . . 16DILANTIN INFATABS . . . . . . . 16DILAUDID . . . . . . . . . . . . . . . . 14diltiazem . . . . . . . . . . . . . . . . . . 10diltiazem extended-release . . 10diltiazem sustained-release . . 10DIMEATAPP DRO

DECONGES . . . . . . . . . . . 22dimenhydrinate . . . . . . . . . . . . 63DIMETAPP . . . . . . 49, 51, 61, 62DIMETAPP CLD ELX/

ALLERGY . . . . . . . . . . . . . 49DIMETAPP DRO DCON/CGH 51DIMETAPP DRO DECONGES 62DIMETAPP SYP CGH/CLD . . 49dimethyl fumarate . . . . . . . . . . 15DIP/TET PED INJ . . . . . . . . . . 58DIPENTUM . . . . . . . . . . . . . . . 27diphenhydramine . . . . . . .21, 43diphenoxylate/atropine . . . . . 26diphtheria-tetanus tox

adsorbed (dt) im . . . . . . . . 58DIPROLENE . . . . . . . . . . . . . . 18DIPROLENE AF . . . . . . . . . . . 18dipyridamole . . . . . . . . . . . . . . . 7DISALCID . . . . . . . . . . . . . . . . . 35disopyramide . . . . . . . . . . . . . . . 9

disopyramide extended-release . . . . . . . . 9

disulfiram . . . . . . . . . . . . . . . . . 41DITROPAN . . . . . . . . . . . . . . . . 54DITROPAN XL . . . . . . . . . . . . . 54DIURIL . . . . . . . . . . . . . . . . . . . 10DIURIL ORAL SUSPENSION 10divalproex sodium cap

sprinkle . . . . . . . . 14, 15, 42divalproex sodium delayed-

release . . . . . . . . . 15, 16, 42divalproex sodium SR 24hr . . 45docosanol . . . . . . . . . . . . .31, 61docusate calcium plus . . . . . . 25docusate potasssium . . . . . . . 25docusate sodium . . . . . . . . . . 25dofetilide. . . . . . . . . . . . . . . . . . . 9dolutegravir . . . . . . . . . . . .31, 33dolutegravir/rilpivirine . . . . . . . 33DOMEBORO . . . . . . . . . . .21, 62DOMEBORO OTIC . . . . . . . . . 21donepezil . . . . . . . . . . . . . . . . . 12dornase alfa . . . . . . . . . . . . . . . 57dorzolamide . . . . . . . . . . . . . . . 39dorzolamide/timolol maleate 39DOSTINEX . . . . . . . . . . . . . . . . 25DOVONEX . . . . . . . . . . . . . . . . 19doxazosin . . . . . . . . . . . . . . . 8, 54doxepin . . . . . . . . . . . . . . . . . . 42doxycycline monohydrate . . . 30doxylamine succinate . . . .43, 63DRAMAMINE . . . . . . . . . . . . . 63DRISDOL . . . . . . . . . . . . . . . . . 55dronabinol . . . . . . . . . . . . . . . . 26DROXIA . . . . . . . . . . . . . . . . . . . 6DUAVEE . . . . . . . . . . . . . . . . . . 38dulaglutide . . . . . . . . . . . . . . . . 24DULCOLAX . . . . . . . . . . . . . . . 63duloxetine . . . . . . . . . . . . .42, 45DUOFILM . . . . . . . . . . . . . .19, 65DUONEB . . . . . . . . . . . . . . . . . 53DURAGESIC . . . . . . . . . . . . . . 13DURATUSS DM ELX . . . . . . . 50DUREX . . . . . . . . . . . . . . . . . . . 62DURICEF . . . . . . . . . . . . . . . . . 29DYANAVEL XR . . . . . . . . . . . . 43

72


Index of Covered DrugsDYAZIDE . . . . . . . . . . . . . . . . . 10

EE-OINTMENT . . . . . . . . . . . . . 61E.E.S. . . . . . . . . . . . . . . . . . . . . 29ecothiophate . . . . . . . . . . . . . . 39ECOTRIN . . . . . . . . . . . 7, 34, 64ED A-HIST TABLETS AND

LIQUID . . . . . . . . . . . . . . . . 49EDGE OB CHW . . . . . . . . . . . 56edoxaban . . . . . . . . . . . . . . . . . . 7EDURANT . . . . . . . . . . . . . . . . 32efavirenz . . . . . . . . . . . . . . .31, 32efavirenz/emtricitabine/

tenofovir . . . . . . . . . . . . . . . 32efavirenz/lamivudine/tenofovir

disoproxil fumarate . . . . . . 32EFFEXOR . . . . . . . . . . . . . . . . . 42EFFEXOR XR . . . . . . . . . . . . . . 42EFFIENT . . . . . . . . . . . . . . . . . . . 7EFUDEX . . . . . . . . . . . . . . . . . . 20EGRIFTA . . . . . . . . . . . . . . . . . 25ELAVIL . . . . . . . . . . . . . . . .14, 42ELDEPRYL . . . . . . . . . . . . . . . . 15electrolyte . . . . . . . . . . . . . .55, 63electrolyte rehydrating soln . . 63ELIDEL . . . . . . . . . . . . . . . . . . . 20ELIMITE . . . . . . . . . . . . . . . . . . 19ELIQUIS . . . . . . . . . . . . . . . . . . . 7ELMIRON . . . . . . . . . . . . . . . . . 54ELOCON . . . . . . . . . . . . . . . . . 18eltrombopag . . . . . . . . . . . . . . 58elvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate . . . 33

EMCYT . . . . . . . . . . . . . . . . . . . . 4EMEND . . . . . . . . . . . . . . . . . . 26EMETROL . . . . . . . . . . . . . . . . 63emicizumab-kxwh . . . . . . . . . . . 8EMLA . . . . . . . . . . . . . . . . . . . . 20emollients . . . . . . . . . . . . . . . . . 61EMSAM . . . . . . . . . . . . . . . . . . 47emtricitabine . . . . . . . . . . .32, 33emtricitabine/rilpivirine/

tenofovir . . . . . . . . . . . . . . . 32

emtricitabine/tenofovir alafenamide . . . . . . . . .32, 33

emtricitabine/tenofovir disoproxil . . . . . . . . . . . . . . 32

EMTRIVA . . . . . . . . . . . . . . . . . 32enalapril . . . . . . . . . . . . . . . . . . . 8enalapril oral soln . . . . . . . . . . . 8enalapril/hydrochlorothiazide . 8ENBREL . . . . . . . . . . . . . . . . . . 34enfuvirtide . . . . . . . . . . . . . . . . 33ENGERIX-B . . . . . . . . . . . . . . . 58enoxaparin . . . . . . . . . . . . . . . . . 7entacapone . . . . . . . . . . . . . . . 15entecavir . . . . . . . . . . . . . . . . . . 31ENTERIC COATED-

NAPROSYN . . . . . . . . .13, 35ENTOCORT EC . . . . . . . . . . . . 27ENTRESTO . . . . . . . . . . . . . . . . 9ENULOSE . . . . . . . . . . . . . . . . 25EPANED . . . . . . . . . . . . . . . . . . . 8epinephrine . . . . . . . . . . . . . . . 57EPIPEN . . . . . . . . . . . . . . . . . . . 57EPIPEN JR. . . . . . . . . . . . . . . . 57EPIVIR . . . . . . . . . . . . . . . .31, 32EPIVIR HBV . . . . . . . . . . . . . . . 31epoetin alfa . . . . . . . . . . . . . . . . 7EPOGEN . . . . . . . . . . . . . . . . . . 7EPZICOM . . . . . . . . . . . . . . . . . 32EQUANIL . . . . . . . . . . . . . . . . . 46EQUETRO . . . . . . . . . . . . . . . . 44ergocalciferol (D2) . . . . . . . . . 55ergotamine tartrate/caffeine . 14ergotamine/caffeine . . . . . . . . 14ERIVEDGE . . . . . . . . . . . . . . . . . 7erlotinib . . . . . . . . . . . . . . . . . . . 4ertugliflozin . . . . . . . . . . . . . . . 24ertugliflozin/metformin . . . . . . 24ERY-TAB . . . . . . . . . . . . . . . . . . 29ERYC . . . . . . . . . . . . . . . . . . . . 29ERYGEL . . . . . . . . . . . . . . . . . . 17ERYTHROCIN . . . . . . . . . . . . . 29erythromycin . . . . . . . 17, 29, 40erythromycin delayed-release 29erythromycin ethylsuccinate . 29erythromycin stearate . . . . . . . 29erythromycin/sulfisoxazole . . 29

ESBRIET . . . . . . . . . . . . . . . . . 58escitalopram . . . . . . . . . . .42, 45escitalopram 10mg &

methylfolate-B12-B6-D thpk . . . . . . . . . . . . . . . . . . 45

escitalopram oxalate soln . . . 45ESGIC . . . . . . . . . . . . . . . . . . . . 13ESKALITH CR . . . . . . . . . . . . . 42esomeprazole . . . . . . . . . . . . . 26esomeprazole granules . . . . . 26ESTRACE . . . . . . . . . . . . . . . . . 37ESTRACE CRM. . . . . . . . . . . . 37estradiol . . . . . . . . . . . . . . . . . . 37estramustine phosphate

sodium . . . . . . . . . . . . . . . . . 4estrogens, conjugated . . . . . . 37estrogens, conjugated/

medroxyprogesterone . . . 37estropipate . . . . . . . . . . . . . . . . 37ESTROSTEP FE . . . . . . . . . . . 37etanercept . . . . . . . . . . . . . . . . 34ethambutol . . . . . . . . . . . . . . . . 29ethionamide . . . . . . . . . . . . . . . 29ethosuximide . . . . . . . . . . . . . . 16ethynodiol diacetate/EE . . . . . 36etidronate . . . . . . . . . . . . . . . . . 25etodolac . . . . . . . . . . . . . . .13, 35etonogestrel/EE . . . . . . . . . . . 36etoposide . . . . . . . . . . . . . . . . . . 6etravirine . . . . . . . . . . . . . . . . . . 31EUCRISA . . . . . . . . . . . . . . . . . 20EULEXIN . . . . . . . . . . . . . . . . . . 5EURAX . . . . . . . . . . . . . . . . . . . 19EVEKEO . . . . . . . . . . . . . . . . . . 43everolimus . . . . . . . . . . . . . . . 4, 6EVISTA . . . . . . . . . . . . . . . . . . . 25EVZIO . . . . . . . . . . . . . . . . . . . . 46EXCEDRIN MIGRAINE . . . . . . 13EXELON . . . . . . . . . . . . . . . . . . 12exemestane . . . . . . . . . . . . . . . . 5EXJADE . . . . . . . . . . . . . . . . . . . 7exogabine . . . . . . . . . . . . . . . . 16ezetimibe . . . . . . . . . . . . . . . . . 11

Ffamotidine . . . . . . . . . . . . .27, 63

73



FANAPT . . . . . . . . . . . . . . . . . . 45FANTASY . . . . . . . . . . . . . . . . . 62FARESTON . . . . . . . . . . . . . . . . 5FARYDAK . . . . . . . . . . . . . . . . . . 4FAZACLO . . . . . . . . . . . . . . . . . 44febuxostat . . . . . . . . . . . . . . . . 35felbamate . . . . . . . . . . . . . . . . . 16felbamate oral susp . . . . . . . . 16FELBATOL . . . . . . . . . . . . . . . . 16FELBATOL ORAL SUSP . . . . 16FELDENE . . . . . . . . . . . . . .13, 35felodipine extended-release . . 9FEMARA . . . . . . . . . . . . . . . . . . 5fenofibrate . . . . . . . . . . . . . . . . 11fentanyl transdermal . . . . . . . . 13FEOSOL . . . . . . . . . . . . . . .55, 64FERGON . . . . . . . . . . . . . . . . . 64ferrous bis-glycinate chelate . 64ferrous fumarate . . . . . . . . . . . 64ferrous gluconate . . . . . . . . . . 64ferrous sulfate . . . . . . . . . .55, 64FETZIMA . . . . . . . . . . . . . . . . . 45fidaxomicin . . . . . . . . . . . . . . . 29filgrastim . . . . . . . . . . . . . . . . . . . 7FINACEA . . . . . . . . . . . . . . . . . 17finasteride . . . . . . . . . . . . . . . . 54fingolimod . . . . . . . . . . . . . . . . 15FIORICET . . . . . . . . . . . . . . . . . 13FIORICET W/CODEINE . . . . . 13FIORINAL . . . . . . . . . . . . . . . . . 13FIORINAL W/CODEINE . . . . . 13FIRAZYR . . . . . . . . . . . . . . . . . 58FLAGYL . . . . . . . . . . . . . . .33, 38flecainide . . . . . . . . . . . . . . . . . . 9FLEET ENEMA . . . . . . . . . . . . 63FLEET PHOSPHO-SODA . . . 63FLEXERIL . . . . . . . . . . . . . . . . . 35FLOMAX. . . . . . . . . . . . . . . . . . 54FLONASE . . . . . . . . . . . . . . . . . 22FLORAJEN . . . . . . . . . . . .28, 63FLORANEX . . . . . . . . . . . .28, 63FLORASTOR . . . . . . . . . . .28, 63FLORINEF . . . . . . . . . . . . . . . . 23FLOXIN . . . . . . . . . . . . . . . .21, 29FLOXIN OTIC . . . . . . . . . . . . . . 21FLUARIX QUAD . . . . . . . . . . . 59

FLUBLOK . . . . . . . . . . . . . . . . . 59FLUCELVAX . . . . . . . . . . . . . . . 59fluconazole . . . . . . . . . . . .30, 38fludrocortisone . . . . . . . . . . . . 23FLULAVAL QUAD . . . . . . . . . . 59FLUMADINE . . . . . . . . . . . . . . 31fluocinolone acetonide . . . . . . 18fluocinonide . . . . . . . . . . . . . . . 18fluocinonide emulsified base 18fluoride . . . . . . . . . . . . 55, 56, 65fluoride dental rinse . . . . . . . . 65fluorometholone . . . . . . . . . . . 39fluorouracil . . . . . . . . . . . . . . . . 20fluoxetine . . . . . . . . . . . . . .42, 45fluoxetine capsule . . . . . . . . . . 45fluoxetine HCL (PMDD) tabs . 45fluoxetine HCL cap delayed-

release 90 mg . . . . . . . . . . 45fluoxetine tablet . . . . . . . . . . . . 45fluphenazine . . . . . . . . . . . . . . 49fluphenazine decanoate . . . . 49flurazepam . . . . . . . . . . . . . . . . 43flurbiprofen . . . . . . . . . . . . . . . 39flutamide . . . . . . . . . . . . . . . . . . 5fluticasone . . . . . . . . . 18, 22, 53fluticasone furoate . . . . . . . . . 53fluticasone propionate . . . . . . 18fluticasone/salmeterol . . . . . . 53fluticasone/vilanterol . . . . . . . 53FLUVIRIN . . . . . . . . . . . . . . . . . 59fluvoxamine . . . . . . . . . . . .41, 45fluvoxamine maleate cap SR

24HR . . . . . . . . . . . . . . . . . 45FLUZONE HD PF . . . . . . . . . . 59FLUZONE QUAD. . . . . . . . . . . 59FLUZONE SPLT . . . . . . . . . . . 59FML . . . . . . . . . . . . . . . . . . . . . . 39FML FORTE . . . . . . . . . . . . . . . 39FML LIQUIFILM . . . . . . . . . . . . 39FOCALIN . . . . . . . . . . . . . . . . . 45FOCALIN XR . . . . . . . . . . . . . . 45folic acid . . . . . . . . . . . . . . .55, 56FOLTABS PAK PLUS DHA RE

OB + DHA PAK . . . . . . . . . 56FOLTABS PRENATAL . . . . . . . 56FORFIVO XL . . . . . . . . . . . . . . 44

FORTICAL . . . . . . . . . . . . . . . . 25FOSAMAX . . . . . . . . . . . . . . . . 25fosamprenavir . . . . . . . . . . . . . 33fosinopril. . . . . . . . . . . . . . . . . . . 8fosinopril/hydrochlorothiazide 8FURADANTIN SUSP

25 MG/5 ML . . . . . . . . . . . 33furosemide . . . . . . . . . . . . . . . . 10FUZEON . . . . . . . . . . . . . . . . . . 33

Ggabapentin . . . . . . . . . . . . . . . . 16GABITRIL . . . . . . . . . . . . . . . . . 16galantamine . . . . . . . . . . . . . . . 12ganciclovir . . . . . . . . . . . . . . . . 31GARDASIL . . . . . . . . . . . . . . . . 58GARDASIL 9 . . . . . . . . . . . . . . 58GATTEX . . . . . . . . . . . . . . . . . . 28gefitinib . . . . . . . . . . . . . . . . . . . . 4GEL-KAM . . . . . . . . . . . . . . . . . 55gemfibrozil . . . . . . . . . . . . . . . . 11GENGRAF . . . . . . . . . . . . . . . . . 6GENTAK . . . . . . . . . . . . . . .17, 40gentamicin . . . . . . . . . 17, 38, 40gentamicin/prednisolone

acetate . . . . . . . . . . . . . . . . 38GENTEX ADE 28-1 MG . . . . . 56GENVOYA . . . . . . . . . . . . . . . . 33GEODON . . . . . . . . . . . . . . . . . 48GG/CODEINE . . . . . . . . . . . . . 50GG/DM CR . . . . . . . . . . . . . . . 50GILENYA . . . . . . . . . . . . . . . . . 15GILOTRIF . . . . . . . . . . . . . . . . . . 4glatiramer acetate . . . . . . . . . . 15GLATOPA . . . . . . . . . . . . . . . . . 15glecaprevir/pibrentasvir . . . . . 31GLEEVEC . . . . . . . . . . . . . . . . . 5GLEOSTINE . . . . . . . . . . . . . . . . 4glimepiride . . . . . . . . . . . . . . . . 24glipizide . . . . . . . . . . . . . . . . . . 24glipizide extended-release . . . 24GLUCAGON . . . . . . . . . . . . . . 23glucagon, human

recombinant . . . . . . . . . . . 23GLUCOPHAGE . . . . . . . . . . . . 24

74


Index of Covered DrugsGLUCOPHAGE ER . . . . . . . . . 24glucose oral tablets . . . . . . . . 62GLUCOTROL . . . . . . . . . . . . . 24GLUCOTROL XL . . . . . . . . . . . 24GLUCOVANCE . . . . . . . . . . . . 24glyburide . . . . . . . . . . . . . . . . . 24glyburide, micronized . . . . . . . 24glycerin . . . . . . . . . . . . 25, 38, 61GLYCERIN SUPPOSITORY . . 25GLYCERIN TOPICAL . . . . . . . 61glycerol phenylbutyrate . . . . . 58glycopyrrolate . . . . . . . . . . . . . 27GLYNASE . . . . . . . . . . . . . . . . . 24GRIFULVIN V . . . . . . . . . . . . . . 30GRIS-PEG . . . . . . . . . . . . . . . . 30griseofulvin microsize . . . . . . . 30griseofulvin ultramicrosize . . . 30guaifenesin . . . . . . . . . . . . 50-52guaifenesin extended-release 51guaifenesin/

pseudoephedrine . . . .50, 51guaifenesin/pseudoephedrine

extended-release . . . . . . . 51guaifenesin/pseudoephedrine/

dextromethorphan . . . . . . 51guanabenz . . . . . . . . . . . . . . . . 12guanfacine . . . . . . . . . . . . . . 8, 41guanfacine ER . . . . . . . . . . . . . 41GUIATUSS AC . . . . . . . . . . . . . 50GUIATUSS DAC . . . . . . . . . . . 50GYNE-LOTRIMIN . . . . . . .38, 61GYNOL II . . . . . . . . . . . . . . . . . 62

HHAEGARDA . . . . . . . . . . . . . . . 58HALCION . . . . . . . . . . . . . . . . . 43HALDOL . . . . . . . . . . . . . . .45, 49HALDOL CONCENTRATE . . 45HALDOL DECANOATE . . . . . 49halobetasol . . . . . . . . . . . . . . . 18haloperidol . . . . . . . . . . . . .45, 49haloperidol decanoate . . . . . . 49haloperidol lactate oral conc . 45HAVRIX . . . . . . . . . . . . . . . . . . . 58HECORIA . . . . . . . . . . . . . . . . . . 6HEMLIBRA . . . . . . . . . . . . . . . . 8

heparin . . . . . . . . . . . . . . . . . . . . 7hepatitis a vaccine susp . . . . . 58hepatitis b vaccine

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

adjuvanted . . . . . . . . . . . . . 58HEPLISAV-B . . . . . . . . . . . . . . 58HEXALEN . . . . . . . . . . . . . . . . . 4HIPREX . . . . . . . . . . . . . . . . . . 54homatropine . . . . . . . . . . .39, 51HUMALOG MIX 50/50. . . . . . 23HUMALOG MIX 75/25. . . . . . 23human papillomavirus (hpv)

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

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

HUMATIN . . . . . . . . . . . . . . . . . 34HUMIRA . . . . . . . . . . . . . . . . . . 34HUMULIN. . . . . . . . . . 23, 24, 62HUMULIN 70/30 . . . . . . . . . . 23HUMULIN N . . . . . . . . . . . . . . . 23HUMULIN R . . . . . . . . . . . . . . . 24HYCAMTIN . . . . . . . . . . . . . . . . 7HYCODAN . . . . . . . . . . . . . . . . 51hydralazine. . . . . . . . . . . . . . . . 12HYDREA . . . . . . . . . . . . . . . . . . 6hydrochlorothiazide . . . . . . 8-10hydrocodone ER . . . . . . . . . . . 14hydrocodone/acetaminophen 14hydrocodone/homatropine . . 51HYDROCODONE/TAB

HOMATROP . . . . . . . . . . . 51hydrocortisone . 18, 20, 21, 23,

27, 38, 62, 63hydrocortisone butyrate . . . . . 18hydrocortisone crm, oint . . . . 62hydrocortisone valerate . . . . . 18hydrocortisone/aloe . . . . . . . . 18HYDROMET SYP . . . . . . . . . . 51hydromorphone . . . . . . . . . . . 14hydroxychloroquine . . . . .33, 34hydroxyurea . . . . . . . . . . . . . . . . 6hydroxyzine HCL . . . . . . . . . . . 21hydroxyzine pamoate . . . . . . . 21hyoscyamine . . . . . . . . . . .27, 54

hyoscyamine sulfate . . . . . . . . 27hyoscyamine sulfate extended-

release . . . . . . . . . . . . . . . . 27HYPERCARE 15% . . . . . . . . . 20HYPERSAL . . . . . . . . . . . . . . . 57HYPERTET S/D . . . . . . . . . . . 59HYPOTEARS . . . . . . . . . . . . . . 64HYTONE . . . . . . . . . . . . . . . . . 18HYTRIN . . . . . . . . . . . . . . . . 8, 54HYZAAR . . . . . . . . . . . . . . . . . . 9

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

COLD/SIN . . . . . . . . . . . . . 52ibuprofen . . . . . . . . . . 13, 35, 64ibuprofen tabs, chew tabs,

drops, susp . . . . . . . . . . . . 64icatibant . . . . . . . . . . . . . . . . . . 58ICLUSIG . . . . . . . . . . . . . . . . . . . 5idelalisib . . . . . . . . . . . . . . . . . . . 5ILARIS . . . . . . . . . . . . . . . . . . . 34iloperidone . . . . . . . . . . . . . . . . 45imatinib mesylate . . . . . . . . . . . 5IMBRUVICA . . . . . . . . . . . . . . . . 5IMDUR . . . . . . . . . . . . . . . . . . . 11imipramine HCL . . . . . . . . . . . 42imipramine pamoate . . . . . . . 45imiquimod 5% cream . . . . . . . 20IMITREX . . . . . . . . . . . . . . . . . . 14IMITREX 4 MG AND

6 MG INJ . . . . . . . . . . . . . . 14IMODIUM A-D . . . . . . . . . .26, 63IMPAVIDO . . . . . . . . . . . . . . . . 30IMURAN . . . . . . . . . . . . . . . . 6, 34INCRELEX . . . . . . . . . . . . . . . . 24INCRUSE ELLIPTA . . . . . . . . . 53indacaterol . . . . . . . . . . . . . . . . 53indapamide . . . . . . . . . . . . . . . 10INDERAL . . . . . . . . . . . . . . . 9, 15INDERAL LA . . . . . . . . . . . . . . . 9INDERIDE . . . . . . . . . . . . . . . . . 9indinavir . . . . . . . . . . . . . . . . . . 33INDOCIN . . . . . . . . . . . . . .13, 35indomethacin . . . . . . . . . .13, 35

75



INFLAMASE FORTE . . . . . . . . 39influenza virus vaccine

recombinant hemagglutinin (ha) . . . . . . . . . . . . . . . . . . . 59

influenza virus vaccine split . . 59influenza virus vaccine split high-

dose pf . . . . . . . . . . . . . . . . 59influenza virus vaccine split pf 59influenza virus vaccine split

quadrivalent . . . . . . . . . . . . 59influenza virus vaccine tiss-cult

subunit . . . . . . . . . . . . . . . . 59influenza virus vaccine types

a&b surface antigen . . . . . 59INGREZZA . . . . . . . . . . . . . . . . 17INLYTA . . . . . . . . . . . . . . . . . . . . 4insulin (vials only) . . . . . . . . . . 62insulin aspart protamine 70%/

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

regular 30% . . . . . . . . . . . . 23insulin isophane/regular . . . . 23insulin lisopro pro/lispro . . . . 23insulin lisopro prot/lispro . . . . 23insulin lispro . . . . . . . . . . . . . . . 24insulin regular . . . . . . . . . . . . . 24insulin syringes . . . . . . . . . . . . 58INTAL . . . . . . . . . . . . . . . . . . . . 53INTELENCE . . . . . . . . . . . . . . . 31interferon alfa-2b . . . . . . . . . 6, 31interferon gamma-1b . . . . . . . . 6INTRON A . . . . . . . . . . . . . . 6, 31INTUNIV . . . . . . . . . . . . . . . . . . 41INVEGA . . . . . . . . . . . . . . .47, 48INVEGA SUSTENNA . . . . . . . 48INVEGA TRINZA . . . . . . . . . . . 48INVIRASE . . . . . . . . . . . . . . . . . 33ipratropium . . . . . . . . . . . .22, 53ipratropium HFA . . . . . . . . . . . 53ipratropium nasal . . . . . . . . . . 22

ipratropium/albuterol . . . . . . . 53IRENKA . . . . . . . . . . . . . . . . . . 45IRESSA . . . . . . . . . . . . . . . . . . . . 4iron . . . . . . . . 36, 37, 55, 56, 64ISENTRESS . . . . . . . . . . . . . . . 31ISENTRESS CHEWABLE . . . 31ISENTRESS HD . . . . . . . . . . . 31ISENTRESS SUSP . . . . . . . . . 31ISMO . . . . . . . . . . . . . . . . . . . . . 11isocarboxazid . . . . . . . . . . . . . 45isoniazid . . . . . . . . . . . . . . . . . . 29ISOPTO ATROPINE . . . . . . . . 39ISOPTO CARPINE . . . . . . . . . 40ISOPTO HOMATROPINE. . . . 39ISOPTO HYOSCINE . . . . . . . . 39ISORDIL . . . . . . . . . . . . . . . . . . 11ISORDIL S.L. . . . . . . . . . . . . . . 11isosorbide dinitrate . . . . . . . . . 11ISOSORBIDE DINITRATE ER 11isosorbide dinitrate extended-

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

extended-release . . . . . . . 11isotretinoin . . . . . . . . . . . . . . . . 17itraconazole . . . . . . . . . . . . . . . 30ivacaftor . . . . . . . . . . . . . . . . . . 57ivermectin . . . . . . . . . . . . . . . . 28ixazomib . . . . . . . . . . . . . . . . . . . 5

JJADENU . . . . . . . . . . . . . . . . . . . 7JAKAFI . . . . . . . . . . . . . . . . . . . . 5JULUCA . . . . . . . . . . . . . . . . . . 33

KK-DUR 10 . . . . . . . . . . . . . . . . . 57K-DUR 20 . . . . . . . . . . . . . . . . . 57K-LOR . . . . . . . . . . . . . . . . . . . . 57K-LYTE . . . . . . . . . . . . . . . . . . . 57K-PHOS NEUTRAL . . . . . . . . . 57K-PHOS ORIGINAL . . . . . . . . 57KALETRA . . . . . . . . . . . . . . . . 33KALYDECO . . . . . . . . . . . . . . . 57KALYDECO GRANULES . . . . 57KAOPECTATE . . . . . . . . . . . . . 63

KAPVAY . . . . . . . . . . . . . . . . . . 44KAYEXALATE . . . . . . . . . . . . . 11KAZANO . . . . . . . . . . . . . . . . . 24KEFLEX . . . . . . . . . . . . . . . . . . 29KENALOG . . . . . . . . . . . . .18, 22KENALOG IN ORABASE . . . . 22KEPPRA . . . . . . . . . . . . . . . . . . 16KERLONE . . . . . . . . . . . . . . . . . 9ketoconazole . . . . . . . 19, 20, 30ketoprofen . . . . . . . . . . . . .13, 35ketorolac . . . . . . . . . . . . . .13, 39ketorolac tromethamine . . . . . 13ketotifen . . . . . . . . . . . . . . . . . . 38KEVZARA . . . . . . . . . . . . . . . . 34KHEDEZLA . . . . . . . . . . . . . . . 44KIMONO. . . . . . . . . . . . . . . . . . 62KINERET . . . . . . . . . . . . . . . . . 34KLONOPIN . . . . . . . . 15, 41, 44KLONOPIN WAFER . . . . . . . . 44KLOR-CON 10 . . . . . . . . . . . . 57KLOR-CON 8 . . . . . . . . . . . . . 57KORLYM . . . . . . . . . . . . . . . . . 25KUVAN . . . . . . . . . . . . . . . . . . . 25KUVAN POWDER FOR

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

Llabetalol . . . . . . . . . . . . . . . . . . . 9LAC-HYDRIN . . . . . . . . . . . . . . 20lacosamide . . . . . . . . . . . . . . . 16LACTINEX . . . . . . . . . . . . .28, 63LACTINOL . . . . . . . . . . . . . . . . 20lactulose . . . . . . . . . . . . . . . . . . 25LAMICTAL . . . . . . . . . . . . .16, 45LAMICTAL CD CHEW TAB . . 16LAMICTAL ODT . . . . . . . . . . . 45LAMICTAL STARTER KIT . . . 16LAMICTAL XR . . . . . . . . . . . . . 45LAMISIL . . . . . . . . . . . . . . .19, 30LAMISIL AT . . . . . . . . . . . . . . . 19lamivudine . . . . . . . . . . . . . 31-33lamivudine/tenofovir disoproxil

fumarate . . . . . . . . . . . . . . . 32lamivudine/zidovudine . . . . . . 32lamotrigine . . . . . . . . . . . . .16, 45

76


Index of Covered Drugslamotrigine chew dispersable

tab . . . . . . . . . . . . . . . . . . . . 16lamotrigine ODT . . . . . . . . . . . 45lamotrigine SR 24hr . . . . . . . . 45lamotrigine starter kit . . . . . . . 16lancets . . . . . . . . . . . . . . . . . . . 58LANOXIN . . . . . . . . . . . . . . . . . . 9lansoprazole . . . . . . . . . . . . . . 27lansoprazole delayed-release 27lapatinib ditosylate . . . . . . . . . . 5LARIAM . . . . . . . . . . . . . . . . . . 33LASIX . . . . . . . . . . . . . . . . . . . . 10latanoprost . . . . . . . . . . . . . . . . 40LATUDA . . . . . . . . . . . . . . . . . . 46laxative enemas . . . . . . . . . . . 63laxatives . . . . . . . . . . . . 2, 25, 63leflunomide . . . . . . . . . . . . . . . 34lenalidomide . . . . . . . . . . . . . . . 6lenvatinib . . . . . . . . . . . . . . . . . . 5LENVIMA . . . . . . . . . . . . . . . . . . 5LETAIRIS . . . . . . . . . . . . . . . . . 12letrozole . . . . . . . . . . . . . . . . . . . 5leucovorin . . . . . . . . . . . . . . . . . 5LEUKERAN . . . . . . . . . . . . . . . . 4LEUKINE . . . . . . . . . . . . . . . . . . 7leuprolide . . . . . . . . . . . . . . . . . . 5levalbuterol HCl . . . . . . . . . . . . 53LEVAQUIN . . . . . . . . . . . . . . . . 29levetiracetam . . . . . . . . . . . . . . 16levobunolol . . . . . . . . . . . . . . . 39levocetirizine . . . . . . . . . . . . . . 21levofloxacin . . . . . . . . . . . . . . . 29levomilnacipran . . . . . . . . . . . . 45levonorgestrel . . . . . . . . . .36, 37levonorgestrel/EE . . . . . . .36, 37levothyroxine . . . . . . . . . . . . . . 25LEVOXYL . . . . . . . . . . . . . . . . . 25LEVSIN . . . . . . . . . . . . . . . . . . . 27LEVSINEX . . . . . . . . . . . . . . . . 27LEXAPRO . . . . . . . . . . . . .42, 45LEXAPRO ORAL SOLUTION 45LEXIVA . . . . . . . . . . . . . . . . . . . 33LIBRIUM . . . . . . . . . . . . . . . . . . 41LIDAMANTEL . . . . . . . . . . . . . 20LIDEX . . . . . . . . . . . . . . . . . . . . 18LIDEX E . . . . . . . . . . . . . . . . . . 18

lidocaine . . . . . . . . . . . . . . .20, 22lidocaine patch . . . . . . . . . . . . 20lidocaine viscous . . . . . . . . . . 22lidocaine/prilocaine . . . . . . . . 20LIDODERM . . . . . . . . . . . . . . . 20LIFESTYLES . . . . . . . . . . . . . . 62lifitegrast . . . . . . . . . . . . . . . . . . 40LIMBITROL DS . . . . . . . . . . . . 44linaclotide . . . . . . . . . . . . . . . . . 25linezolid . . . . . . . . . . . . . . . . . . 33LINZESS . . . . . . . . . . . . . . . . . . 25liothyronine . . . . . . . . . . . . . . . 25liotrix . . . . . . . . . . . . . . . . . . . . . 25LIPITOR . . . . . . . . . . . . . . . . . . 11lisdexamfetamine . . . . . . . . . . 41lisdexamfetamine

chewable tab . . . . . . . . . . . 41lisinopril . . . . . . . . . . . . . . . . 8, 88lisinopril/hydrochlorothiazide . 8lithium carbonate . . . . . . . . . . 42lithium carbonate extended-

release . . . . . . . . . . . . . . . . 42LITHOBID . . . . . . . . . . . . . . . . . 42lixisenatide . . . . . . . . . . . . .23, 24LMX-4 . . . . . . . . . . . . . . . . . . . . 20LO/OVRAL . . . . . . . . . . . . . . . . 36LOCOID . . . . . . . . . . . . . . . . . . 18LODINE . . . . . . . . . . . . . . .13, 35LOESTRIN 1/20 . . . . . . . . . . . 36LOESTRIN 1.5/30 . . . . . . . . . 36LOESTRIN FE 1/20 . . . . . . . . 36LOESTRIN FE 1.5/30 . . . . . . . 36LOFIBRA . . . . . . . . . . . . . . . . . 11LOHIST-D . . . . . . . . . . . . . . . . . 50LOMOTIL . . . . . . . . . . . . . . . . . 26lomustine . . . . . . . . . . . . . . . . . . 4LONITEN . . . . . . . . . . . . . . . . . 12LONSURF . . . . . . . . . . . . . . . . . 4loperamide . . . . . . . . . . . . . . . . 26LOPID . . . . . . . . . . . . . . . . . . . . 11lopinavir/ritonavir . . . . . . . . . . 33LOPRESSOR . . . . . . . . . . . . . . . 9loratadine . . . . . . . 21, 22, 51, 61loratadine & pseudoephedrine

SR 24hr . . . . . . . . . . . . . . . 51

loratadine/ pseudoephedrine 22, 51, 61

loratadine/pseudoephedrine extended-release . . . . . . . 22

lorazepam . . . . . . . . . . . . .41, 45lorazepam concentrate

solution . . . . . . . . . . . . . . . 45LORAZEPAM INTENSOL . . . 45LORCET . . . . . . . . . . . . . . . . . . 14LORTAB . . . . . . . . . . . . . . . . . . 14LORTAB ELIXIR . . . . . . . . . . . 14losartan . . . . . . . . . . . . . . . . . 8, 9losartan/HCTZ . . . . . . . . . . . . . 9LOTENSIN . . . . . . . . . . . . . . . . . 8LOTENSIN HCT . . . . . . . . . . . . 8LOTRIMIN AF . . . . . . . . . .19, 61LOTRISONE . . . . . . . . . . . . . . . 19lovastatin . . . . . . . . . . . . . . . . . 11LOVAZA . . . . . . . . . . . . . . . . . . 11LOVENOX . . . . . . . . . . . . . . . . . 7loxapine . . . . . . . . . . . . . . .46, 49loxapine aerosol powder

breath activated . . . . . . . . 46LOXITANE . . . . . . . . . . . . . . . . 49LOZOL . . . . . . . . . . . . . . . . . . . 10LUDIOMIL . . . . . . . . . . . . . . . . 43lumacaftor/ivacaftor . . . . . . . . 57LUPRON . . . . . . . . . . . . . . . . . . 5LUPRON DEPOT . . . . . . . . . . . 5LUPRON DEPOT 6-MONTH . . 5LUPRON DEPOT-PED . . . . . . . 5lurasidone . . . . . . . . . . . . . . . . 46LURIDE . . . . . . . . . . . . . . . . . . . 55LURIDE LOZI-TABS. . . . . . . . . 55LUVOX . . . . . . . . . . . . . . . .41, 45LUVOX CR . . . . . . . . . . . . . . . . 45LYNPARZA . . . . . . . . . . . . . . . . 6LYRICA . . . . . . . . . . . . . . . . . . . 16LYRICA SOLUTION . . . . . . . . 16LYSODREN . . . . . . . . . . . . . . . . 6LYSTEDA . . . . . . . . . . . . . . . . . 38

MM-CLEAR WC . . . . . . . . . . . . . 50M-M-R II . . . . . . . . . . . . . . . . . . 59MAALOX . . . . . . . . . . . . . .26, 63

77



MAALOX LIQUID . . . . . . . . . . 63macitentan . . . . . . . . . . . . . . . . 12MACROBID . . . . . . . . . . . . . . . 33MACRODANTIN . . . . . . . . . . . 33MAG-OX . . . . . . . . . . . . . . .55, 64magnesium citrate soln . . . . . 26magnesium oxide . . . . . . .55, 64malathion . . . . . . . . . . . . . . . . . 19MAPAP COLD TAB . . . . . . . . 52maprotiline . . . . . . . . . . . . . . . . 43maraviroc . . . . . . . . . . . . . . . . . 33MARINOL . . . . . . . . . . . . . . . . . 26MARPLAN . . . . . . . . . . . . . . . . 45MATERNA . . . . . . . . . . . . . . . . 56MATULANE . . . . . . . . . . . . . . . . 7MAVIK . . . . . . . . . . . . . . . . . . . . . 8MAVYRET . . . . . . . . . . . . . . . . 31MAXALT/MAXALT MLT . . . . . 14MAXITROL. . . . . . . . . . . . . . . . 38MAXZIDE . . . . . . . . . . . . . . . . . 10measles, mumps & rubella virus

vaccines for inj . . . . . . . . . 59mecasermin . . . . . . . . . . . . . . . 24meclizine . . . . . . . . . . . . . .26, 63MEDROL . . . . . . . . . . . . . . . . . 23medroxyprogesterone

acetate . . . . . . . . . . . . .36, 37mefloquine . . . . . . . . . . . . . . . . 33MEGACE . . . . . . . . . . . . . . . . . . 6megestrol acetate . . . . . . . . . . . 6MEKINIST . . . . . . . . . . . . . . . . . 5MELLARIL . . . . . . . . . . . . . . . . 49meloxicam . . . . . . . . . . . . .13, 35melphalan . . . . . . . . . . . . . . . . . 4memantine . . . . . . . . . . . . . . . . 12MENACTRA . . . . . . . . . . . . . . . 59meningococcal (a, c, y, and

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

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

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

MENOMUNE . . . . . . . . . . . . . . 59

MENVEO . . . . . . . . . . . . . . . . . 59meperidine . . . . . . . . . . . . . . . . 14MEPHYTON . . . . . . . . . . . . . . 55meprobamate tablet . . . . . . . . 46MEPRON . . . . . . . . . . . . . . . . . 30mercaptopurine . . . . . . . . . . . . . 4mesalamine . . . . . . . . . . . . . . . 27mesalamine

extended-release . . . . . . . 27mesalamine supp . . . . . . . . . . 27mesna . . . . . . . . . . . . . . . . . . . . . 5MESNEX . . . . . . . . . . . . . . . . . . 5MESTINON . . . . . . . . . . . . . . . 15MESTINON TIMESPAN . . . . . 15METADATE CD . . . . . . . . .41, 46METADATE ER . . . . . . . . . . . . 41METAMUCIL . . . . . . . . . . . . . . 63metaproterenol . . . . . . . . . . . . 53METAPROTERENOL

SYRUP . . . . . . . . . . . . . . . . 53metformin . . . . . . . . . . . . . . . . . 24metformin ER . . . . . . . . . . . . . 24metformin/glyburide . . . . . . . . 24methamphetamine . . . . . . . . . 46methazolamide . . . . . . . . . . . . 39methenamine . . . . . . . . . . . . . 54methenamine hippurate . . . . . 54METHERGINE . . . . . . . . . .25, 38methimazole . . . . . . . . . . . . . . 25methocarbamol . . . . . . . . . . . . 35methotrexate . . . . . . . . . . . . . . 34methoxsalen . . . . . . . . . . . . . . 19methsuximide . . . . . . . . . . . . . 16methyldopa . . . . . . . . . . . . . . . 12methyldopa/HCTZ . . . . . . . . . 12methylene blue . . . . . . . . . . . . 54methylergonovine . . . . . . .25, 38METHYLIN . . . . . . . . . . . . . . . . 46methylphenidate . . . . 41, 42, 46methylphenidate chew tabs . 46methylphenidate extended

release disintegrating . . . . 46methylphenidate extended-

release . . . . . . . . . . . . .41, 46methylphenidate extended-

release suspension . . . . . 46

methylphenidate HCL cap CR . . . . . . . . . . . . . . . . 46

methylphenidate hcl chew tab extended release . . . . . . . 46

methylphenidate HCL ER 24hr . . . . . . . . . . . . . . . . . . 42

methylphenidate patch. . . . . . 46methylprednisolone . . . . . . . . 23metipranolol . . . . . . . . . . . . . . . 39metoclopramide . . . . . . . . . . . 26metolazone . . . . . . . . . . . . . . . 10metoprolol . . . . . . . . . . . . . . . . . 9metoprolol succinate . . . . . . . . 9METROCREAM . . . . . . . . . . . 19METROGEL . . . . . . . . . . . .19, 38METROGEL 1% . . . . . . . . . . . 38METROGEL-VAGINAL . . . . . . 38METROLOTION . . . . . . . . . . . 19metronidazole . . . . . . 19, 33, 38MEVACOR . . . . . . . . . . . . . . . . 11mexiletine . . . . . . . . . . . . . . . . . . 9MEXITIL . . . . . . . . . . . . . . . . . . . 9MIACALCIN . . . . . . . . . . . . . . . 25MICATIN . . . . . . . . . . . . . . .19, 61miconazole . . . . . . . . 19, 38, 61miconazole crm . . . . . . . . . . . 61MICRO-K 10 . . . . . . . . . . . . . . 57MICRONASE . . . . . . . . . . . . . . 24MICROZIDE . . . . . . . . . . . . . . . 10MIDAMOR . . . . . . . . . . . . . . . . 10midodrine . . . . . . . . . . . . . . . . . 12midostaurin . . . . . . . . . . . . . . . . 5mifepristone . . . . . . . . . . . . . . . 25MIGERGOT

SUPPOSITORIES . . . . . . . 14miltefosine . . . . . . . . . . . . . . . . 30MINIPRESS . . . . . . . . . . . . . . . . 8MINOCIN . . . . . . . . . . . . . . . . . 30minocycline . . . . . . . . . . . . . . . 30minoxidil . . . . . . . . . . . . . . . . . . 12MINUTUSS DR SYP . . . . . . . . 51MIRALAX . . . . . . . . . . . . . . . . . 26MIRAPEX . . . . . . . . . . . . . . . . . 15MIRCETTE . . . . . . . . . . . . . . . . 36mirtazapine . . . . . . . . . . . .43, 46mirtazapine ODT . . . . . . . . . . . 46

78



MIRVASO . . . . . . . . . . . . . . . . . 19misoprostol . . . . . . . . . . . . . . . 28MITIGARE . . . . . . . . . . . . . . . . 35mitotane . . . . . . . . . . . . . . . . . . . 6MOBAN . . . . . . . . . . . . . . . . . . 46MOBIC . . . . . . . . . . . . . . . .13, 35MODICON . . . . . . . . . . . . . . . . 36MODURETIC . . . . . . . . . . . . . . 10molindone . . . . . . . . . . . . . . . . 46mometasone . . . . . . . . . . .18, 53mometasone furoate . . . . . . . 18MONISTAT . . . . . . . . . . . . .38, 61MONISTAT 3 . . . . . . . . . . . . . . 38MONISTAT-DERM . . . . . . . . . . 19MONOPRIL . . . . . . . . . . . . . . . . 8MONOPRIL-HCT . . . . . . . . . . . . 8montelukast . . . . . . . . . . . . . . . 54morphine . . . . . . . . . . . . . . . . . 14morphine extended-release . . 14MOTRIN . . . . . . . . . . . 13, 35, 64MOTRIN IB . . . . . . . . . . . . . . . 64MOVANTIK . . . . . . . . . . . . . . . 28MOZOBIL . . . . . . . . . . . . . . . . . . 7MS CONTIN . . . . . . . . . . . . . . . 14MSIR . . . . . . . . . . . . . . . . . . . . . 14MUCINEX . . . . . . . . . . . . . .50, 51MUCINEX D . . . . . . . . . . . . . . . 51MUCINEX DM . . . . . . . . . . . . . 50MUCOMYST . . . . . . . . . . . . . . 57MULTI SYMPTOM TAB COLD

RLF . . . . . . . . . . . . . . . . . . . 52multivitamins/fluoride/±iron . 55multivitamins/minerals . . . . . . 55mupirocin . . . . . . . . . . . . . . . . . 17MURINE . . . . . . . . . . . . . . . . . . 64MURO 128 . . . . . . . . . . . . . . . 40MYAMBUTOL . . . . . . . . . . . . . 29MYCELEX . . . . . . . . . . . . .19, 30MYCOBUTIN . . . . . . . . . . . . . . 29mycophenolate mofetil . . . . . . . 6mycophenolate sodium . . . . . . 6MYCOSTATIN . . . . . . . . . .19, 30MYDAYIS . . . . . . . . . . . . . . . . . 43MYFORTIC. . . . . . . . . . . . . . . . . 6MYLANTA . . . . . . . . . . . . .26, 63

MYLANTA LIQUID . . . . . . . . . 63MYLERAN . . . . . . . . . . . . . . . . . 4MYLICON . . . . . . . . . . . . . . . . . 63MYORISAN . . . . . . . . . . . . . . . 17MYSOLINE . . . . . . . . . . . . . . . . 16MYTESI . . . . . . . . . . . . . . . . . . 26

Nnabumetone . . . . . . . . . . . . . . 13naloxegol . . . . . . . . . . . . . . . . . 28naloxone . . . . . . . . . . . . . . .46, 47naloxone hcl solution auto-

injector . . . . . . . . . . . . . . . . 46NALOXONE INJ . . . . . . . . . . . 47naltrexone . . . . . . . . . . . . .41, 47NAMENDA . . . . . . . . . . . . . . . . 12naphazoline HCL . . . . . . . . . . 38naphazoline/glycerin . . . . . . . 38naphazoline/zinc sulfate . . . . 38NAPHCON A . . . . . . . . . . . . . . 64NAPROSYN . . . . . . . . . . . .13, 35naproxen . . . . . . . . . . . . . .13, 35naproxen delayed release 13, 35naratriptan . . . . . . . . . . . . . . . . 14NARCAN NASAL SPRAY . . . 47NARDIL . . . . . . . . . . . . . . . . . . 47NASACORT ALLERGY 24

HOUR . . . . . . . . . . . . . . . . . 22nasal sprays . . . . . . . . . . . . . . . 62NASALCROM . . . . . . . . . . . . . 22nateglinide . . . . . . . . . . . . . . . . 24NATROBA . . . . . . . . . . . . . . . . 19NAVANE . . . . . . . . . . . . . . . . . . 49NEBUPENT . . . . . . . . . . . . . . . 30NEBUSAL . . . . . . . . . . . . . . . . 57nefazodone . . . . . . . . . . . . . . . 46nelfinavir . . . . . . . . . . . . . . . . . . 33NEO-SYNEPHRINE . . . . .22, 62neomycin sulfate . . . . . . . . . . . 33neomycin/bacitracin/

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

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

dexamethasone . . . . . . . . 38

neomycin/polymyxin B/gramicidin . . . . . . . . . . . . . 40

neomycin/polymyxin B/hydrocortisone . . . . . .21, 38

NEORAL . . . . . . . . . . . . . . . . . . 6NEOSPORIN . . . . . . . 17, 40, 62NEPHROCAPS . . . . . . . . . . . . 56NEPTAZANE . . . . . . . . . . . . . . 39NESINA . . . . . . . . . . . . . . . . . . 24NESTABS . . . . . . . . . . . . . . . . . 56NEULASTA . . . . . . . . . . . . . . . . 7NEUMEGA . . . . . . . . . . . . . . . . . 7NEURONTIN . . . . . . . . . . . . . . 16NEUTROGENA OIL FREE

ACNE WASH . . . . . . . . . . . 17nevirapine . . . . . . . . . . . . . . . . 32nevirapine ER . . . . . . . . . . . . . 32NEXAVAR . . . . . . . . . . . . . . . . . 5NEXIUM 24HR OTC . . . . . . . . 26NEXIUM DELAYED RELEASE

PACKET . . . . . . . . . . . . . . . 26niacin . . . . . . . . . . . . . . . . . . . . 11niacin extended-release . . . . . 11NIACOR . . . . . . . . . . . . . . . . . . 11NIASPAN . . . . . . . . . . . . . . . . . 11nicardipine . . . . . . . . . . . . . . . . 10NICODERM CQ . . . . . . . .48, 64NICORETTE OTC . . . . . . . . . . 48nicotine . . . . . . . . . . . . 46, 48, 64NICOTINE GUM . . . . . . . . . . . 64nicotine inhaler system . . . . . 46nicotine nasal spray . . . . . . . . 46nicotine polacrilex gum . . . . . 48nicotine polacrilex lozenge . . 48nicotine TD patch 24 HR kit . 46NICOTROL INHALER. . . . . . . 46NICOTROL NS . . . . . . . . . . . . 46nifedipine . . . . . . . . . . . . . . . . . 10nifedipine extended-release . 10nilotinib . . . . . . . . . . . . . . . . . . . . 5nimodipine . . . . . . . . . . . . . . . . 10nimodipine oral soln . . . . . . . . 10NIMOTOP. . . . . . . . . . . . . . . . . 10NINLARO . . . . . . . . . . . . . . . . . . 5nintedanib . . . . . . . . . . . . . . . . 58niraparib . . . . . . . . . . . . . . . . . . . 6

79



NIRAVAM . . . . . . . . . . . . . . . . . 43nitazoxanide suspension . . . . 30nitazoxanide tablet . . . . . . . . . 30nitisinone . . . . . . . . . . . . . . . . . 25NITREK . . . . . . . . . . . . . . . . . . 11NITRO-BID . . . . . . . . . . . . . . . . 11NITRO-DUR . . . . . . . . . . . . . . . 11nitrofurantoin

extended-release . . . . . . . 33nitrofurantoin macrocrystals . 33nitrofurantoin susp . . . . . . . . . 33nitroglycerin . . . . . . . . . . . .11, 20NITROLINGUAL . . . . . . . . . . . 11NITROSTAT . . . . . . . . . . . . . . . 11NITYR . . . . . . . . . . . . . . . . . . . . 25NIX 19, 63NIX CREME RINSE . . . . . . . . . 19NIZORAL . . . . . . . . . . 19, 20, 30NIZORAL SHAMPOO. . . . . . . 20NOLVADEX . . . . . . . . . . . . . . . . 5NORCO . . . . . . . . . . . . . . . . . . 14NORDETTE . . . . . . . . . . . . . . . 36norelgestromin/EE . . . . . . . . . 37norethindrone . . . . . . . . . .36, 37norethindrone acetate . . .36, 37norethindrone acetate/

EE . . . . . . . . . . . . . . . . .36, 37norethindrone acetate/

EE/iron . . . . . . . . . . . . .36, 37norethindrone/EE . . . . . . .36, 37norethindrone/ME . . . . . . . . . 36NORFLEX . . . . . . . . . . . . . . . . 35norgestimate/EE . . . . . . . .36, 37norgestrel/EE . . . . . . . . . .36, 37NORPACE . . . . . . . . . . . . . . . . . 9NORPACE CR . . . . . . . . . . . . . . 9NORPRAMIN . . . . . . . . . . . . . . 42nortriptyline . . . . . . . . . . . . . . . 42NORVASC . . . . . . . . . . . . . . . . . 9NORVIR . . . . . . . . . . . . . . . . . . 33NOVAREL . . . . . . . . . . . . . . . . 37NOVOLIN . . . . . . . . . . . . . .23, 62NOVOLIN 70/30 . . . . . . . . . . . 23NOVOLIN N . . . . . . . . . . . . . . . 23NOVOLIN R . . . . . . . . . . . . . . . 23NOVOLOG MIX 70/30 . . . . . . 23

NUEDEXTA . . . . . . . . . . . . . . . 48NULYTELY . . . . . . . . . . . . . . . . 26NUPLAZID . . . . . . . . . . . . . . . . 47NUVARING . . . . . . . . . . . . . . . 36NUVIGIL . . . . . . . . . . . . . . . . . . 12NYMALIZE . . . . . . . . . . . . . . . . 10nystatin . . . . . . . . . . . . . . . .19, 30NYTOL QUICK CAPS . . . . . . . 43

OOCEAN NASAL SPRAY . . . . . 22octreotide . . . . . . . . . . . . . . . . . . 6OCUFEN . . . . . . . . . . . . . . . . . 39OCUFLOX . . . . . . . . . . . . . . . . 40ODEFSEY. . . . . . . . . . . . . . . . . 32ODOMZO . . . . . . . . . . . . . . . . . . 7OFEV . . . . . . . . . . . . . . . . . . . . 58ofloxacin . . . . . . . . . . . 21, 29, 40OGEN . . . . . . . . . . . . . . . . . . . . 37olanzapine . . . . . . . . . . . . .46, 48olanzapine INJ. . . . . . . . . . . . . 46olanzapine ODT . . . . . . . . . . . 46olanzapine pamoate for

extended-release IM sus . 46olanzapine-fluoxetine . . . . . . . 46olaparib . . . . . . . . . . . . . . . . . . . 6olodaterol . . . . . . . . . . . . . . . . . 53olsalazine sodium . . . . . . . . . . 27omalizumab . . . . . . . . . . . . . . . 53omega 3 acid ethyl esters . . . 11omeprazole delayed-release . 27OMNICEF . . . . . . . . . . . . . . . . . 29ondansetron . . . . . . . . . . . . . . 26One Touch Systems . . . . . . . . 24One Touch Test Strips . . . . . . 24ONFI . . . . . . . . . . . . . . . . . . . . . 15oprelvekin . . . . . . . . . . . . . . . . . 7OPSUMIT . . . . . . . . . . . . . . . . . 12OPTIPRANOLOL . . . . . . . . . . 39OPTIVAR . . . . . . . . . . . . . . . . . 38ORAP . . . . . . . . . . . . . . . . . . . . 49ORAPRED . . . . . . . . . . . . . . . . 23ORKAMBI . . . . . . . . . . . . . . . . 57orphenadrine

extended-release . . . . . . . 35ORTHO COIL . . . . . . . . . . . . . 36

ortho diaphragm . . . . . . . . . . . 36ORTHO EVRA . . . . . . . . . . . . . 37ORTHO FLAT . . . . . . . . . . . . . 36ORTHO FLEX . . . . . . . . . . . . . 36ORTHO MICRONOR . . . . . . . 37ORTHO TRI-CYCLEN . . . . . . . 37ORTHO-CEPT . . . . . . . . . . . . . 36ORTHO-CYCLEN . . . . . . . . . . 36ORTHO-NOVUM 1/35 . . . . . . 36ORTHO-NOVUM 1/50 . . . . . . 36ORTHO-NOVUM 10/11 . . . . 36ORTHO-NOVUM 7/7/7 . . . . . 37ORUDIS . . . . . . . . . . . . . . .13, 35OS-CAL . . . . . . . . . . . . . . .55, 64oseltamivir . . . . . . . . . . . . . . . . 31OSENI . . . . . . . . . . . . . . . . . . . . 24OTEZLA . . . . . . . . . . . . . . . . . . 34OVCON 50 . . . . . . . . . . . . . . . . 36OVIDE . . . . . . . . . . . . . . . . . . . . 19OVIDREL . . . . . . . . . . . . . . . . . 37OVRAL . . . . . . . . . . . . . . . .36, 37oxaprozin . . . . . . . . . . . . . .13, 35oxazepam . . . . . . . . . . . . . . . . 41oxcarbazepine . . . . . . . . . . . . . 16OXSORALEN-ULTRA . . . . . . . 19oxybutynin chloride . . . . . . . . 54oxybutynin IR . . . . . . . . . . . . . . 54oxybutynin patch. . . . . . . .54, 64oxycodone . . . . . . . . . . . . . . . . 14oxycodone/acetaminophen . 14oxycodone/aspirin . . . . . . . . . 14OXYFAST . . . . . . . . . . . . . . . . . 14oxymetazoline . . . . . . . . . . . . . 22oxymorphone ER . . . . . . . . . . 14OXYTROL FOR WOMEN OTC

PATCH . . . . . . . . . . . . .54, 64

Ppalbociclib . . . . . . . . . . . . . . . . . 5paliperidone . . . . . . . . . . . .47, 48paliperidone tab SR 24HR . . 47palivizumab . . . . . . . . . . . . . . . 33PAMELOR . . . . . . . . . . . . . . . . 42pancrelipase . . . . . . . . . . . . . . 27panobinostat . . . . . . . . . . . . . . . 4PANRETIN . . . . . . . . . . . . . . . . . 6

80


Index of Covered Drugspantoprazole . . . . . . . . . . . . . . 27PARAFON FORTE DSC . . . . . 35PARNATE . . . . . . . . . . . . . . . . . 42paromomycin . . . . . . . . . . . . . 34paroxetine . . . . . . . . . . . . .42, 47paroxetine HCL oral susp . . . 47paroxetine HCL tab SR 24HR 47paroxetine mesylate tab . . . . . 47PASER . . . . . . . . . . . . . . . . . . . 29pasireotide . . . . . . . . . . . . . . . . . 6patiromer . . . . . . . . . . . . . . . . . 11PAXIL . . . . . . . . . . . . . . . . .42, 47PAXIL CR . . . . . . . . . . . . . . . . . 47pazopanib . . . . . . . . . . . . . . . . . 5PEDIACARE LIQ MULTI-SY . . 52PEDIALYTE . . . . . . . . . . . .55, 63PEDIAPRED . . . . . . . . . . . . . . . 23PEDIAZOLE . . . . . . . . . . . . . . . 29peg 3350/electrolytes . . . . . . 26peg 3350/sodium bicarbonate/

sodium chloride . . . . . . . . 26peg 3350/sodium bicarbonate/

sodium chloride/potassium chloride . . . . . . . . . . . . . . . 26

PEGASYS . . . . . . . . . . . . . . . . . 31PEGASYS PROCLICK . . . . . . 31pegfilgrastim . . . . . . . . . . . . . . . 7peginterferon alfa-2a . . . . . . . 31peginterferon alfa-2b . . . . . . . . 6peginterferon beta-1a . . . . . . . 15pegvisomant . . . . . . . . . . . . . . 25penicillamine . . . . . . . . . . . . . . 34penicillin VK . . . . . . . . . . . . . . . 30PENLAC SOLUTION 8% . . . . 19pentamidine isethionate for

nebulization . . . . . . . . . . . . 30pentosan polysulfate . . . . . . . 54pentoxifylline extended-release 8PEPCID . . . . . . . . . . . . . . .27, 63PEPCID AC . . . . . . . . . . . .27, 63PERCOCET . . . . . . . . . . . . . . . 14PERCODAN . . . . . . . . . . . . . . . 14PERIDEX . . . . . . . . . . . . . . . . . 22permethrin . . . . . . . . . . . . .19, 63perphenazine . . . . . . . . . .42, 49PERSANTINE . . . . . . . . . . . . . . 7

PEXEVA . . . . . . . . . . . . . . . . . . 47phenazopyridine . . . . . . . . . . . 54phenelzine . . . . . . . . . . . . . . . . 47PHENERGAN . . . . . . . . . .26, 50PHENERGAN DM . . . . . . . . . . 50phenobarbital . . . . . . . . . . . . . 16phenyl salicylate . . . . . . . . . . . 54phenylephrine . . . . . . . 22, 49-52phenylephrine/

brompheniramine/dextromethorphan . . . . . . 51

phenylephrine/chlorpheniramine/ dextromethorphan . . . . . . 51

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

phenylephrine/dextromethorphan . . .51, 52

phenylephrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 52

phenylephrine/ephed/CPM w/carbetapentane . . . . . . . . 52

phenylephrine/guaifenesin . . 52phenylephrine/pyrilamine w/

hydrocodone . . . . . . . . . . . 52PHENYLHIST LIQ DH . . . . . . 50PHENYTEK . . . . . . . . . . . . . . . 16phenytoin . . . . . . . . . . . . . . . . . 16phenytoin sodium extended . 16PHILLIPS COLON

HEALTH . . . . . . . . . . . .28, 63PHOS-FLUR . . . . . . . . . . .55, 65PHOSLO . . . . . . . . . . . . . . . . . 58PHOSPHOLINE IODINE . . . . 39phosphorus . . . . . . . . . . . . . . . 57PHRENILIN . . . . . . . . . . . . . . . 13phytonadione. . . . . . . . . . . . . . 55pilocarpine . . . . . . . . . . . . .22, 40PILOPINE HS GEL . . . . . . . . . 40pimavanserin . . . . . . . . . . . . . . 47pimecrolimus . . . . . . . . . . . . . . 20pimozide . . . . . . . . . . . . . . . . . 49PIN-X . . . . . . . . . . . . . . . . . . . . . 28pioglitazone . . . . . . . . . . . . . . . 24

pirfenidone capsule . . . . . . . . 58piroxicam . . . . . . . . . . . . . .13, 35PLAN B ONE STEP . . . . . . . . 36PLAQUENIL . . . . . . . . . . . .33, 34PLAVIX . . . . . . . . . . . . . . . . . . . . 7PLEGRIDY . . . . . . . . . . . . . . . . 15PLENDIL . . . . . . . . . . . . . . . . . . 9plerixafor . . . . . . . . . . . . . . . . . . 7PLETAL . . . . . . . . . . . . . . . . . . . 7PLEXION . . . . . . . . . . . . . . . . . 17pneumococcal 13-valent

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

polyvalent. . . . . . . . . . . . . . 59PNEUMOVAX . . . . . . . . . . . . . 59PNEUMOVAX 23 . . . . . . . . . . 59podofilox . . . . . . . . . . . . . . . . . 19POLY-VI-FLOR . . . . . . . . . . . . . 55POLY-VI-SOL . . . . . . . . . . . . . . 64polyethylene glycol 3350 . . . . 26polymyxin B/bacitracin . .17, 40polymyxin B/trimethoprim . . . 40polysaccharide iron caps . . . . 64POLYSPORIN . . . . . . . . . . . . . 40POLYTRIM . . . . . . . . . . . . . . . . 40pomalidomide . . . . . . . . . . . . . . 6POMALYST . . . . . . . . . . . . . . . . 6ponatinib . . . . . . . . . . . . . . . . . . 5potassium acid phosphate . . 57potassium bicarbonate/

potassium citrate effervescent . . . . . . . . . . . . 57

potassium chloride . . . . . .26, 57potassium chloride extended-

release . . . . . . . . . . . . . . . . 57potassium citrate . . . . . . . .54, 57POTIGA . . . . . . . . . . . . . . . . . . 16povidone-iodine . . . . . . . . . . . 34PRALUENT . . . . . . . . . . . . . . . 11pramipexole . . . . . . . . . . . . . . . 15pramlintide . . . . . . . . . . . . . . . . 24PRAMLYTE . . . . . . . . . . . . . . . 45PRANDIN . . . . . . . . . . . . . . . . . 24prasugrel . . . . . . . . . . . . . . . . . . 7praziquantel . . . . . . . . . . . . . . . 28prazosin . . . . . . . . . . . . . . . . . . . 8

81



PRECOSE . . . . . . . . . . . . . . . . 24PRED FORTE . . . . . . . . . . . . . 39PRED MILD . . . . . . . . . . . . . . . 39PRED-G . . . . . . . . . . . . . . . . . . 38prednicarbate . . . . . . . . . . . . . 18prednisolone . . . . . . . 23, 38, 39prednisolone acetate . . . .38, 39prednisolone phosphate . . . . 39prednisolone sodium

phosphate . . . . . . . . . . . . . 23prednisone . . . . . . . . . . . . . . . . 23pregabalin . . . . . . . . . . . . . . . . 16PRELONE . . . . . . . . . . . . . . . . 23PREMARIN . . . . . . . . . . . . . . . 37PREMPHASE . . . . . . . . . . . . . 37PREMPRO . . . . . . . . . . . . . . . . 37prenat w/o A w/fecbn-fegl-DSS-

FA & DHA . . . . . . . . . . . . . . 56prenat-FE Bis-FE prot succ-FA-

CA & omega 3 . . . . . .55, 56prenat-FE bis-FE prot succ-FA-

CA & omega DR . . . . . . . . 56prenatal vit w/ iron

carbonyl-FA . . . . . . . . . . . . 56prenatal vit w/FE bisglycinate

chelate-FA . . . . . . . . . . . . . 56prenatal vit w/FE polysac cmplx-

FA . . . . . . . . . . . . . . . . . . . . 56prenatal vit w/o vit a w/fe

bisglycinate-fa . . . . . . . . . . 56PRENATAL VITAMINS W/

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

FE gluc-DSS-FA . . . . . . . . 56PREPARATION H . . . . . . . . . . 63PREVACID . . . . . . . . . . . . . . . . 27PREVACID SOLUTAB . . . . . . 27PREVIDENT . . . . . . . . . . . . . . . 55PREVNAR 13 . . . . . . . . . . . . . 59PREZCOBIX . . . . . . . . . . . . . . 33PREZISTA . . . . . . . . . . . . . . . . 33PRIFTIN . . . . . . . . . . . . . . . . . . 29PRILOSEC . . . . . . . . . . . . . . . . 27primaquine. . . . . . . . . . . . . . . . 34primidone . . . . . . . . . . . . . . . . . 16

PRINCIPEN . . . . . . . . . . . . . . . 30PRISTIQ . . . . . . . . . . . . . . . . . . 44PROAMATINE . . . . . . . . . . . . . 12probenecid . . . . . . . . . . . . . . . 35probiotics . . . . . . . . . . . . . .28, 63procarbazine . . . . . . . . . . . . . . . 7PROCARDIA . . . . . . . . . . . . . . 10PROCARDIA XL . . . . . . . . . . . 10PROCENTRA . . . . . . . . . . . . . 45prochlorperazine . . . . . . . . . . . 26PROCRIT . . . . . . . . . . . . . . . . . . 7PROCTOSOL HC CREAM

2.5% . . . . . . . . . . . . . . . . . . 20PROCTOZONE CREAM-HC

2.5% . . . . . . . . . . . . . . . . . . 20progesterone micronized cap 37PROGRAF . . . . . . . . . . . . . . . . . 6PROLIXIN . . . . . . . . . . . . . . . . . 49PROLIXIN DECANOATE . . . . 49PROMACTA . . . . . . . . . . . . . . . 58PROMETH VC SYP 6.25-5/5 52promethazine . . . . . . 26, 50, 52promethazine & phenylephrine .

50, 52PROMETHAZINE SYP DM . . 50PROMETHAZINE VC

W/CODEINE . . . . . . . . . . . 50PROMETHAZINE

W/CODEINE . . . . . . . . . . . 50PROMETRIUM . . . . . . . . . . . . 37propafenone . . . . . . . . . . . . . . . 9propantheline . . . . . . . . . . . . . 54propranolol . . . . . . . . . . . . . 9, 15propranolol ER 24HR . . . . . . . 9propranolol/HCTZ . . . . . . . . . . 9propylthiouracil . . . . . . . . . . . . 25PROSCAR . . . . . . . . . . . . . . . . 54PROTONIX . . . . . . . . . . . . . . . . 27PROTOPIC 0.03% . . . . . . . . . 20PROTOPIC 0.1% . . . . . . . . . . . 20protriptyline . . . . . . . . . . . . . . . 47PROVENTIL . . . . . . . . . . . . . . . 53PROVERA . . . . . . . . . . . . . . . . 37PROZAC . . . . . . . . . . . . . .42, 45PROZAC WEEKLY . . . . . . . . . 45

PRUET DHA PAK SETONET PAK . . . . . . . . . . . . . . . . . . . 56

PRUET DHAEC PAK . . . . . . . 56PSE/GG . . . . . . . . . . . . . . . . . . 51pseudoephedrine tan/

dexchlorphen tan/DM tan 52pseudoephedrine/

acetaminophen/dextromethorphan . . . . . . 52

pseudoephedrine/chlorpheniramine/dextromethorphan . . . . . . 52

pseudoephedrine/dextromethorphan/guaifenesin . . . . . . . . . . . . 52

pseudoephedrine/iburprofen 52psyllium . . . . . . . . . . . . . . . . . . 63PULMICORT RESPULES . . . 53PULMOZYME . . . . . . . . . . . . . 57PURINETHOL . . . . . . . . . . . . . . 4pyrantel pamoate . . . . . . . . . . 28pyrazinamide . . . . . . . . . . . . . . 29pyrethrins/piperonyl butoxide

liquid shampoo . . . . . . . . . 63pyrethrins/piperonyl butoxide

shampoo . . . . . . . . . . . . . . 19PYRIDIUM . . . . . . . . . . . . . . . . 54pyridostigmine . . . . . . . . . . . . . 15pyridostigmine

extended-release . . . . . . . 15pyrilamine tan/phenyleph

tan . . . . . . . . . . . . . . . . . . . . 52pyrimethamine . . . . . . . . . . . . 34

QQUESTRAN . . . . . . . . . . . . . . . 11QUESTRAN-LIGHT . . . . . . . . . 11quetiapine . . . . . . . . . . . . .47, 48quetiapine fumarate tab SR

24HR . . . . . . . . . . . . . . . . . 47QUILLICHEW ER . . . . . . . . . . 46QUILLIVANT XR . . . . . . . . . . . 46quinapril . . . . . . . . . . . . . . . . . . . 8quinapril/hydrochlorothiazide . 8QUINIDINE GLUCONATE

EXT-REL . . . . . . . . . . . . . . . 9

82


Index of Covered Drugsquinidine gluconate extended-

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

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

release . . . . . . . . . . . . . . . . . 9QVAR . . . . . . . . . . . . . . . . . . . . 53

RR-TANNAMINE . . . . . . . . . . . . 49raloxifene . . . . . . . . . . . . . . . . . 25raltegravir . . . . . . . . . . . . . . . . . 31raltegravir susp . . . . . . . . . . . . 31ramipril . . . . . . . . . . . . . . . . . . . . 8RANEXA . . . . . . . . . . . . . . . . . 12ranitidine . . . . . . . . . . . . . . . . . 27ranitidine syrup . . . . . . . . . . . . 27ranolazine . . . . . . . . . . . . . . . . 12RAPAMUNE. . . . . . . . . . . . . . . . 6RAVICTI . . . . . . . . . . . . . . . . . . 58RAZADYNE . . . . . . . . . . . . . . . 12REBETOL/COPEGUS . . . . . . 31RECOMBIVAX HB . . . . . . . . . 58rectal hydrocortisone crm,

suppositories . . . . . . . . . . . 63RECTIV . . . . . . . . . . . . . . . . . . . 20REESE’S PINWORM

MEDICINE . . . . . . . . . . . . . 28REGLAN . . . . . . . . . . . . . . . . . 26regorafenib . . . . . . . . . . . . . . . . 5REGRANEX . . . . . . . . . . . . . . . 20RELAFEN . . . . . . . . . . . . . . . . . 13RELENZA. . . . . . . . . . . . . . . . . 31RELION 70/30 . . . . . . . . . . . . 23RELION N . . . . . . . . . . . . . . . . 23RELION R . . . . . . . . . . . . . . . . 23REMERON . . . . . . . . . . . . .43, 46REMERON SOLTAB . . . . . . . . 46RENVELA . . . . . . . . . . . . . . . . 58repaglinide . . . . . . . . . . . . . . . . 24REQUIP . . . . . . . . . . . . . . . . . . 15RESCRIPTOR . . . . . . . . . . . . . 31RESTORIL . . . . . . . . . . . . . . . . 43RETIN-A . . . . . . . . . . . . . . . . . . 17RETROVIR . . . . . . . . . . . . . . . . 32

REVATIO . . . . . . . . . . . . . . . . . 12REVIA . . . . . . . . . . . . . . . . .41, 47REVLIMID . . . . . . . . . . . . . . . . . 6REXULTI . . . . . . . . . . . . . . . . . . 44REYATAZ . . . . . . . . . . . . . . . . . 32REYATAZ POWDER

PACKET . . . . . . . . . . . . . . . 32ribavirin . . . . . . . . . . . . . . . . . . . 31RID SHAMPOO . . . . . . . . .19, 63RIDAURA . . . . . . . . . . . . . . . . . 34rifabutin . . . . . . . . . . . . . . . . . . 29RIFADIN . . . . . . . . . . . . . . . . . . 29rifampin . . . . . . . . . . . . . . . . . . 29rifapentine . . . . . . . . . . . . . . . . 29rilpivirine . . . . . . . . . . . . . . .32, 33RILUTEK . . . . . . . . . . . . . . . . . 12riluzole . . . . . . . . . . . . . . . . . . . 12rimantadine . . . . . . . . . . . . . . . 31riociguat . . . . . . . . . . . . . . . . . . 12RISA-BID . . . . . . . . . . . . . .28, 63RISAQUAD . . . . . . . . . . . . .28, 63RISPERDAL . . . . . . . . . . . .47, 48RISPERDAL CONSTA . . . . . . 48RISPERDAL M-TAB . . . . . . . . 47RISPERDAL SOLUTION . . . . 48risperidone . . . . . . . . . . . . .47, 48risperidone ODT . . . . . . . . . . . 47risperidone oral soln . . . . . . . . 48RITALIN . . . . . . . . . . . . . . . . . . 41RITALIN LA . . . . . . . . . . . . . . . 41ritonavir . . . . . . . . . . . . . . . . . . . 33rivaroxaban . . . . . . . . . . . . . . . . 7rivastigmine . . . . . . . . . . . . . . . 12rizatriptan . . . . . . . . . . . . . . . . . 14RMS . . . . . . . . . . . . . . . . . . . . . 14ROBAXIN . . . . . . . . . . . . . . . . . 35ROBINUL . . . . . . . . . . . . . . . . . 27ROBITUSSIN . . . . . . . . 49-52, 62ROBITUSSIN CF . . . . . . . .51, 62ROBITUSSIN DM . . . . . . .50, 62ROBITUSSIN LIQ

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

CGH/CLD . . . . . . . . . .49, 52ROBITUSSIN LIQ

CGH/CONG . . . . . . . . . . . 50

ROBITUSSIN LIQ HD/CHST . 52ROBITUSSIN LIQ PED

NGHT . . . . . . . . . . . . . . . . . 52ROBITUSSIN PE . . . . . . . .51, 62ROBITUSSIN PED LIQ CGH/

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

CHST CNG . . . . . . . . . . . . 51ROBITUSSIN SYP MAX-ST . . 50ROCALTROL . . . . . . . . . . . . . . 55ROCALTROL SOLUTION . . . 55rolapitant . . . . . . . . . . . . . . . . . 26RONDEC DM . . . . . . . . . . . . . 51RONDEC DM DROPS . . . . . . 51RONDEC DROPS . . . . . . . . . . 49RONDEC SYRUP . . . . . . . . . . 50ropinirole . . . . . . . . . . . . . . . . . 15ROWASA . . . . . . . . . . . . . . . . . 27ROXICODONE . . . . . . . . . . . . 14RUBRACA . . . . . . . . . . . . . . . . . 7rucaparib . . . . . . . . . . . . . . . . . . 7rufinamide . . . . . . . . . . . . . . . . 16ruxolitinib . . . . . . . . . . . . . . . . . . 5RYDAPT . . . . . . . . . . . . . . . . . . . 5RYNA-12 S . . . . . . . . . . . . . . . 52RYNATAN PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 50RYNATUSS PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 52RYTHMOL . . . . . . . . . . . . . . . . . 9

SSABRIL SOLUTION . . . . . . . . 16sacubitril/valsartan . . . . . . . . . . 9SAL-TROPINE . . . . . . . . . . . . . 28SALAGEN . . . . . . . . . . . . . . . . 22salicylic acid . . . . . . . 17, 19, 65salicylic acid 17%/

collodion . . . . . . . . . . .19, 65saline nasal spray 0.65% . . . . 22salsalate . . . . . . . . . . . . . . . . . . 35SANCTURA . . . . . . . . . . . . . . . 54SANDIMMUNE . . . . . . . . . . . . . 6SANDOSTATIN . . . . . . . . . . . . . 6SANTYL . . . . . . . . . . . . . . . . . . 20

83



SAPHRIS . . . . . . . . . . . . . . . . . 44sapropterin . . . . . . . . . . . . . . . . 25sapropterin powder . . . . . . . . 25saquinavir mesylate . . . . . . . . 33SARAFEM . . . . . . . . . . . . . . . . 45sargramostim. . . . . . . . . . . . . . . 7sarilumab . . . . . . . . . . . . . . . . . 34savaysa . . . . . . . . . . . . . . . . . . . . 7SCALPICIN . . . . . . . . . . . . . . . 19scopolamine . . . . . . . . . . . . . . 39SEASONALE . . . . . . . . . . . . . . 36SECTRAL . . . . . . . . . . . . . . . . . . 9secukinumab . . . . . . . . . . . . . . 34SEDAPAP . . . . . . . . . . . . . . . . . 13SEGLUROMET . . . . . . . . . . . . 24selegiline . . . . . . . . . . . . . .15, 47selegiline td patch . . . . . . . . . . 47selenium sulfide . . . . . . . . . . . 20SELSUN . . . . . . . . . . . . . . . . . . 20SELZENTRY . . . . . . . . . . . . . . 33sennosides . . . . . . . . . . . . . . . 26SENOKOT . . . . . . . . . . . . . . . . 26SENSIPAR . . . . . . . . . . . . . . . . 58SERAX . . . . . . . . . . . . . . . . . . . 41SEROMYCIN . . . . . . . . . . . . . . 29SEROQUEL . . . . . . . . . . . .47, 48SEROQUEL XR . . . . . . . . . . . . 47sertraline . . . . . . . . . . . . . . . . . 42SERZONE . . . . . . . . . . . . . . . . 46sevelamer . . . . . . . . . . . . . . . . . 58SHINGRIX . . . . . . . . . . . . . . . . 60SIGNIFOR . . . . . . . . . . . . . . . . . 6sildenafil . . . . . . . . . . . . . . . . . . 12SILVADENE . . . . . . . . . . . . . . . 17silver sulfadiazine . . . . . . . . . . 17simethicone . . . . . . . . . . . .26, 63simvastatin . . . . . . . . . . . . . . . . 11SINEMET . . . . . . . . . . . . . . . . . 15SINEMET CR . . . . . . . . . . . . . . 15SINEQUAN . . . . . . . . . . . . . . . 42SINGULAIR . . . . . . . . . . . . . . . 54sirolimus . . . . . . . . . . . . . . . . . . . 6SIRTURO . . . . . . . . . . . . . . . . . 33sodium chloride for nebulizer 57sodium chloride hypertonic . 40sodium citrate/citric acid . . . . 54

sodium phenylbutyrate . . . . . 58sodium phosphate

monobasic . . . . . . . . . . . . . 54sodium polystyrene sulfonate 11SOLIQUA . . . . . . . . . . . . . . . . . 23somatropin . . . . . . . . . . . . . . . . 24SOMAVERT . . . . . . . . . . . . . . . 25SONATA . . . . . . . . . . . . . . . . . . 43sonidegib . . . . . . . . . . . . . . . . . . 7sorafenib . . . . . . . . . . . . . . . . . . 5SORIATANE . . . . . . . . . . . . . . . 19sotalol . . . . . . . . . . . . . . . . . . . . . 9sotalol AF . . . . . . . . . . . . . . . . . . 9spacers . . . . . . . . . . . . . . . . . . . 58spinosad . . . . . . . . . . . . . . . . . 19spironolactone. . . . . . . . . . . . . 10spironolactone/

hydrochlorothiazide . . . . . 10SPORANOX . . . . . . . . . . . . . . . 30SPRYCEL . . . . . . . . . . . . . . . . . . 4STADOL . . . . . . . . . . . . . . . . . . 13STARLIX . . . . . . . . . . . . . . . . . . 24STATUSS DM SYP . . . . . . . . . 51stavudine . . . . . . . . . . . . . . . . . 32STAVZOR . . . . . . . . . . . . . . . . . 47STEGLATRO . . . . . . . . . . . . . . 24STELAZINE . . . . . . . . . . . . . . . 49STIOLTO . . . . . . . . . . . . . . . . . . 53STIVARGA . . . . . . . . . . . . . . . . . 5stool softeners . . . . . . . . . . . . . 63STRATTERA . . . . . . . . . . . . . . 44STRENSIQ . . . . . . . . . . . . . . . . 25STRIBILD . . . . . . . . . . . . . . . . . 33STRIVERDI RESPIMAT . . . . . 53STROMECTOL . . . . . . . . . . . . 28STUART PRENATAL . . . . . . . 64SUBOXONE . . . . . . . . . . . .44, 47SUBUTEX . . . . . . . . . . . . . . . . 47succimer . . . . . . . . . . . . . . . . . 57sucralfate . . . . . . . . . . . . . . . . . 27sugar+orthophosphoric acid 63sulcralfate . . . . . . . . . . . . . . . . . 27SULFACET-R . . . . . . . . . . . . . . 17sulfacetamide . . . . . . 17, 38, 40sulfacetamide/pred phos . . . 38sulfacetamide/sulfur . . . . . . . . 17

sulfamethoxazole/ trimethoprim, DS . . . . . . . 30

sulfasalazine . . . . . . . . . . .27, 34sulfasalazine

delayed-release . . . . . .27, 34sulindac . . . . . . . . . . . . . . .13, 35sumatriptan . . . . . . . . . . . . . . . 14sunitinib . . . . . . . . . . . . . . . . . . . 5SUPRAX . . . . . . . . . . . . . . . . . . 29SURMONTIL . . . . . . . . . . . . . . 47SUSTIVA . . . . . . . . . . . . . . . . . . 31SUTENT . . . . . . . . . . . . . . . . . . . 5SYLATRON . . . . . . . . . . . . . . . . 6SYMBYAX . . . . . . . . . . . . . . . . 46SYMFI . . . . . . . . . . . . . . . . . . . . 32SYMFI LO . . . . . . . . . . . . . . . . . 32SYMLIN . . . . . . . . . . . . . . . . . . 24SYMMETREL . . . . . . . . . .15, 31SYNAGIS . . . . . . . . . . . . . . . . . 33SYNALAR . . . . . . . . . . . . . . . . 18SYNTHROID . . . . . . . . . . . . . . 25

TT-STAT . . . . . . . . . . . . . . . . . . . 17TABLOID . . . . . . . . . . . . . . . . . . 4tacrolimus . . . . . . . . . . . . . . 6, 20TAFINLAR . . . . . . . . . . . . . . . . . 4TAGAMET . . . . . . . . . . . . . . . . 26TAMBOCOR . . . . . . . . . . . . . . . 9TAMIFLU . . . . . . . . . . . . . . . . . 31tamoxifen . . . . . . . . . . . . . . . . . . 5tamsulosin . . . . . . . . . . . . . . . . 54TANAFED DMX

SUSPENSION . . . . . . . . . . 52TANZEUM . . . . . . . . . . . . . . . . 24TAPAZOLE . . . . . . . . . . . . . . . . 25TARCEVA . . . . . . . . . . . . . . . . . . 4TARGRETIN . . . . . . . . . . . . . . . . 6TASIGNA . . . . . . . . . . . . . . . . . . 5TASMAR . . . . . . . . . . . . . . . . . . 15TECFIDERA . . . . . . . . . . . . . . . 15teduglutide . . . . . . . . . . . . . . . . 28TEGRETOL . . . . . . . . . . . . . . . 15TEGRETOL-XR . . . . . . . . . . . . 15temazepam . . . . . . . . . . . . . . . 43TEMODAR . . . . . . . . . . . . . . . . . 4

84


Index of Covered DrugsTEMOVATE . . . . . . . . . . . . . . . 18temozolomide . . . . . . . . . . . . . . 4TENEX . . . . . . . . . . . . . . . . . . . . 8TENIVAC . . . . . . . . . . . . . . . . . 59tenofovir . . . . . . . . . . . . . . .32, 33TENORETIC . . . . . . . . . . . . . . . 9TENORMIN . . . . . . . . . . . . . . . . 9TERAZOL 3/7 . . . . . . . . . . . . . 38terazosin . . . . . . . . . . . . . . . . 8, 54terbinafine . . . . . . . . . . . . .19, 30terbutaline . . . . . . . . . . . . . . . . 53terconazole . . . . . . . . . . . . . . . 38teriflunomide . . . . . . . . . . . . . . 15tesamorelin . . . . . . . . . . . . . . . 25TESSALON . . . . . . . . . . . . . . . 49TESTOSTERONE 1% TOPICAL

GEL . . . . . . . . . . . . . . . . . . 23testosterone cypionate . . . . . . 23testosterone enanthate . . . . . . 23testosterone gel topical tube,

packet, and pump bottle . 23tet tox-diph-acell pertuss ad . 59TET/DIP TOX INJ . . . . . . . . . . 59tetanus immune globulin

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

(td) . . . . . . . . . . . . . . . . . . . 59tetrabenazine . . . . . . . . . . . . . . 17tetrahydrozoline/zinc sulfate . 38thalidomide . . . . . . . . . . . . . . . . 6THALOMID . . . . . . . . . . . . . . . . 6THEO-24 . . . . . . . . . . . . . . . . . 54THEOCHRON . . . . . . . . . . . . . 54theophylline . . . . . . . . . . . . . . . 54theophylline extended-release 54thioguanine . . . . . . . . . . . . . . . . 4thioridazine . . . . . . . . . . . . . . . 49thiothixene . . . . . . . . . . . . . . . . 49THORAZINE . . . . . . . . . . . . . . 48THYROLAR . . . . . . . . . . . . . . . 25tiagabine . . . . . . . . . . . . . . . . . 16TIAZAC . . . . . . . . . . . . . . . . . . . 10ticagrelor . . . . . . . . . . . . . . . . . . 7TIGAN . . . . . . . . . . . . . . . . . . . . 26TIKOSYN . . . . . . . . . . . . . . . . . . 9timolol . . . . . . . . . . . . . . . . . . . . 39

timolol maleate . . . . . . . . . . . . 39TIMOPTIC . . . . . . . . . . . . . . . . 39TIMOPTIC XE . . . . . . . . . . . . . 39TINACTIN . . . . . . . . . . . . . .19, 61tiotropium/olodaterol . . . . . . . 53tipranavir . . . . . . . . . . . . . . . . . 33TIVICAY . . . . . . . . . . . . . . . . . . 31tizanidine . . . . . . . . . . . . . . . . . 35TOBRADEX . . . . . . . . . . . . . . . 39tobramycin . . . . . . . . . 39, 40, 57tobramycin neb soln . . . . . . . . 57tobramycin/dexamethasone . 39TOBREX . . . . . . . . . . . . . . . . . . 40TOFRANIL . . . . . . . . . . . . . . . . 42TOFRANIL-PM . . . . . . . . . . . . . 45tolazamide . . . . . . . . . . . . . . . . 24tolbutamide . . . . . . . . . . . . . . . 24tolcapone . . . . . . . . . . . . . . . . . 15TOLINASE . . . . . . . . . . . . . . . . 24tolnaftate . . . . . . . . . . . . . .19, 61tolterodine . . . . . . . . . . . . . . . . 54TOPAMAX . . . . . . . . . . . . . . . . 16TOPAMAX SPRINKLE . . . . . . 16topical antibacterials . . . . . . . . 62topiramate . . . . . . . . . . . . . . . . 16topiramate sprinkle caps . . . . 16topotecan . . . . . . . . . . . . . . . . . . 7TOPROL XL . . . . . . . . . . . . . . . . 9TORADOL . . . . . . . . . . . . . . . . 13toremifene . . . . . . . . . . . . . . . . . 5torsemide . . . . . . . . . . . . . . . . . 10TOUJEO SOLOSTAR . . . . . . . 23TRACLEER . . . . . . . . . . . . . . . 12tramadol . . . . . . . . . . . . . . . . . . 13trametinib . . . . . . . . . . . . . . . . . . 5TRANDATE . . . . . . . . . . . . . . . . 9trandolapril . . . . . . . . . . . . . . . . . 8tranexamic acid . . . . . . . . . . . . 38TRANXENE . . . . . . . . . . . . . . . 41tranylcypromine . . . . . . . . . . . . 42trazodone . . . . . . . . . . . . . .43, 47TRECATOR . . . . . . . . . . . . . . . 29TRENTAL . . . . . . . . . . . . . . . . . . 8tretinoin . . . . . . . . . . . . . . . . 7, 17TRI RX . . . . . . . . . . . . . . . . . . . 56TRI-FED X. . . . . . . . . . . . . . . . . 52

TRI-NORINYL . . . . . . . . . . . . . 37TRI-VI-FLOR . . . . . . . . . . . . . . . 56TRI-VI-SOL . . . . . . . . . . . . .57, 64triamcinolone . . . . . . . . . . .18, 22triamcinolone acetonide . . . . 18triamcinolone nasal spray . . . 22triamterene/

hydrochlorothiazide . . . . . 10TRIAVIL . . . . . . . . . . . . . . . . . . 42triazolam . . . . . . . . . . . . . . . . . . 43trifluoperazine . . . . . . . . . . . . . 49trifluridine . . . . . . . . . . . . . . . 4, 40trifluridine/tipiracil . . . . . . . . . . . 4trihexyphenidyl . . . . . . . . . . . . 15TRILAFON . . . . . . . . . . . . . . . . 49TRILEPTAL . . . . . . . . . . . . . . . 16TRILYTE . . . . . . . . . . . . . . . . . . 26trimethobenzamide . . . . . . . . 26trimethoprim . . . . . . . 30, 34, 40trimipramine . . . . . . . . . . . . . . 47TRINTELLIX . . . . . . . . . . . . . . . 47TRIOTANN . . . . . . . . . . . . .22, 49TRIOTANN PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 49tripolidine/pseudoephedrine 52TRIPROL/PSE SYP . . . . . . . . 52TRIUMEQ . . . . . . . . . . . . . . . . . 33TRIVORA . . . . . . . . . . . . . . . . . 37TRIZIVIR . . . . . . . . . . . . . . . . . . 32TROJAN . . . . . . . . . . . . . . . . . . 62trospium . . . . . . . . . . . . . . . . . . 54TRULICITY . . . . . . . . . . . . . . . . 24TRUSOPT . . . . . . . . . . . . . . . . 39TRUST NATALCARE PAK

DHA . . . . . . . . . . . . . . . . . . 56TRUSTEX . . . . . . . . . . . . . . . . . 62TRUVADA . . . . . . . . . . . . . . . . 32TUMS . . . . . . . . . . . . . . . . .63, 64TUSSI-12 S . . . . . . . . . . . . . . . 49TUSSIN DM . . . . . . . . . . . . . . . 50TYBOST . . . . . . . . . . . . . . . . . . 33TYKERB . . . . . . . . . . . . . . . . . . . 5TYLENOL . . . . . . . . . . 13, 34, 64TYLENOL W/CODEINE . . . . . 13TYMLOS . . . . . . . . . . . . . . . . . 25typhoid vaccine . . . . . . . . . . . . 60

85



UULORIC . . . . . . . . . . . . . . . . . . 35ULTRA . . . . . . . . . . . . . . . . . . . 24ULTRA 2, ULTRAMINI . . . . . . 24ULTRAM . . . . . . . . . . . . . . . . . . 13ULTRAVATE . . . . . . . . . . . . . . . 18umeclidinium inhalation . . . . . 53UNI-HIST DROps . . . . . . . . . . 49UNIPHYL . . . . . . . . . . . . . . . . . 54UNISOM . . . . . . . . . . . . . . .43, 63UREA . . . . . . . . . . . . . . . . . . . . 20UREA 10% CREAM . . . . . . . . 20UREA 10% LOTION . . . . . . . . 20urea 10%, urea 20% . . . . . . . . 20UREA 20% CREAM . . . . . . . . 20urea 40% . . . . . . . . . . . . . . . . . 20URECHOLINE . . . . . . . . . . . . . 54UREX . . . . . . . . . . . . . . . . . . . . 54uridine . . . . . . . . . . . . . . . . . . . 25UROCIT-K . . . . . . . . . . . . . . . . 54UROXATRAL . . . . . . . . . . . . . . 54URSO . . . . . . . . . . . . . . . . . . . . 28URSO FORTE . . . . . . . . . . . . . 28ursodiol . . . . . . . . . . . . . . . . . . 28UTIRA C . . . . . . . . . . . . . . . . . . 54

VVAGIFEM . . . . . . . . . . . . . . . . . 37vaginal products . . . . . . . . . . . 61valacyclovir . . . . . . . . . . . . . . . . 31valbenazine . . . . . . . . . . . . . . . 17VALCYTE . . . . . . . . . . . . . . . . . 31valganciclovir . . . . . . . . . . . . . . 31VALIUM . . . . . . . . . . . . . . .35, 41valproic acid . . . . . . . . . . .16, 47valproic acid cap delayed-

release . . . . . . . . . . . . . . . . 47VALTREX . . . . . . . . . . . . . . . . . 31VANCOCIN HCL . . . . . . . . . . . 30vancomycin HCl . . . . . . . . . . . 30vandetanib . . . . . . . . . . . . . . . . . 5VAQTA . . . . . . . . . . . . . . . . . . . 58varenicline . . . . . . . . . . . . . . . . 48varicella virus vac live for

subcutaneous . . . . . . . . . . 60VARIVAX . . . . . . . . . . . . . . . . . 60

VARUBI . . . . . . . . . . . . . . . . . . 26VASERETIC . . . . . . . . . . . . . . . . 8VASOCIDIN . . . . . . . . . . . . . . . 38VASOCLEAR . . . . . . . . . . . . . . 38VASOCLEAR A . . . . . . . . . . . . 38VASOTEC . . . . . . . . . . . . . . . . . . 8VECTICAL . . . . . . . . . . . . . . . . 19VEETIDS . . . . . . . . . . . . . . . . . 30VELTASSA . . . . . . . . . . . . . . . . 11vemurafenib . . . . . . . . . . . . . . . . 5VENCLEXTA . . . . . . . . . . . . . . . 5venetoclax . . . . . . . . . . . . . . . . . 5venlafaxine . . . . . . . . . . . . .42, 47venlafaxine HCL tab

SR 24HR . . . . . . . . . . . . . . 47venlafaxine XR . . . . . . . . . . . . . 42VENTOLIN HFA . . . . . . . . . . . . 53VEPESID . . . . . . . . . . . . . . . . . . 6verapamil . . . . . . . . . . . . . .10, 15verapamil extended-release . . 10VERIO . . . . . . . . . . . . . . . . . . . . 24VERIO, VERIO FLEX, VERIO IQ,

VERIO SYNC . . . . . . . . . . . 24VERSACLOZ . . . . . . . . . . . . . . 44VERZENIO . . . . . . . . . . . . . . . . . 4VESANOID . . . . . . . . . . . . . . . . . 7vfend . . . . . . . . . . . . . . . . . . . . . 30VI-DAYLIN . . . . . . . . . . . . . . . . . 64VICODIN . . . . . . . . . . . . . . . . . . 14VICODIN ES . . . . . . . . . . . . . . . 14VIDEX . . . . . . . . . . . . . . . . . . . . 32VIDEX EC . . . . . . . . . . . . . . . . . 32vigabatrin oral solution . . . . . . 16VIIBRYD . . . . . . . . . . . . . . . . . . 47vilazodone . . . . . . . . . . . . . . . . 47VIMPAT . . . . . . . . . . . . . . . . . . . 16VINATE AZ EX . . . . . . . . . . . . . 56VINATE II . . . . . . . . . . . . . . . . . 56VIRACEPT . . . . . . . . . . . . . . . . 33VIRAMUNE . . . . . . . . . . . . . . . 32VIRAMUNE XR . . . . . . . . . . . . 32VIREAD . . . . . . . . . . . . . . . . . . 32VIROPTIC . . . . . . . . . . . . . . . . . 40VISINE . . . . . . . . . . . . . . . . . . . 64VISINE-AC . . . . . . . . . . . . . . . . 38vismodegib . . . . . . . . . . . . . . . . 7

VISTARIL . . . . . . . . . . . . . . . . . 21VISTOGARD . . . . . . . . . . . . . . 25vitamin A . . . . . . . . . . . . . . . . . 56vitamin ADC/fluoride/±iron

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

folic acid . . . . . . . . . . . . . . . 56vitamin B-1 . . . . . . . . . . . . . . . . 56VITAMIN B-12 . . . . . . . . . . . . . 55vitamin B-6 . . . . . . . . . . . . . . . . 56vitamin C . . . . . . . . . . . . . . . . . 56VITAMIN D 1000 UNIT . . . . . . 55VITAMIN D 2000 UNIT . . . . . . 55vitamin D 400 IU . . . . . . . . . . . 64VITAMIN D 400 UNIT . . . . . . . 55vitamins pediatric . . . . . . .57, 64vitamins pediatric members <3

years old . . . . . . . . . . . . . . 64vitamins prenatal . . . . . . . . . . . 64VIVACTIL . . . . . . . . . . . . . . . . . 47VIVOTIF BERNA . . . . . . . . . . . 60VOLTAREN . . . . . 13, 34, 35, 39VOLTAREN 1% TOPICAL

GEL . . . . . . . . . . . . . . . . . . 34VOLTAREN XR . . . . . . . . .13, 35voriconazole . . . . . . . . . . . . . . 30vorinostat . . . . . . . . . . . . . . . . . . 4vortioxetine. . . . . . . . . . . . . . . . 47VOSOL HC OTIC . . . . . . . . . . 21VOSOL OTIC . . . . . . . . . . . . . . 21VOTRIENT . . . . . . . . . . . . . . . . . 5VRAYLAR . . . . . . . . . . . . . . . . . 44VYVANSE . . . . . . . . . . . . . . . . 41VYVANSE CHEWABLE . . . . . 41

Wwarfarin . . . . . . . . . . . . . . . . . . . 7WELLBUTRIN . . . . . . . . . . . . . 43WELLBUTRIN SR . . . . . . . . . . 43WELLBUTRIN XL . . . . . . . . . . 43WESTCORT . . . . . . . . . . . . . . . 18WYTENSIN . . . . . . . . . . . . . . . 12

XXALATAN . . . . . . . . . . . . . . . . . 40XALKORI . . . . . . . . . . . . . . . . . . 4

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Index of Covered DrugsXANAX . . . . . . . . . . . . . . . .41, 43XANAX XR . . . . . . . . . . . . . . . . 43XARELTO . . . . . . . . . . . . . . . . . . 7XELODA . . . . . . . . . . . . . . . . . . . 4XENAZINE . . . . . . . . . . . . . . . . 17XIIDRA . . . . . . . . . . . . . . . . . . . 40XOLAIR . . . . . . . . . . . . . . . . . . 53XOPENEX RESPULES . . . . . . 53XULANE . . . . . . . . . . . . . . . . . . 37XYLOCAINE . . . . . . . . . . . .20, 22XYZAL . . . . . . . . . . . . . . . . . . . 21

Yyuvafem or estradiol vaginal

tablet . . . . . . . . . . . . . . . . . 37

Zzaleplon . . . . . . . . . . . . . . . . . . 43ZANAFLEX . . . . . . . . . . . . . . . 35zanamivir . . . . . . . . . . . . . . . . . 31ZANTAC . . . . . . . . . . . . . . . . . . 27ZARONTIN . . . . . . . . . . . . . . . 16ZAROXOLYN . . . . . . . . . . . . . . 10ZARXIO . . . . . . . . . . . . . . . . . . . 7ZEBETA . . . . . . . . . . . . . . . . . . . 9ZEBUTAL . . . . . . . . . . . . . . . . . 13ZEJULA . . . . . . . . . . . . . . . . . . . 6ZELBORAF . . . . . . . . . . . . . . . . 5ZENPEP . . . . . . . . . . . . . . . . . . 27ZENTANE . . . . . . . . . . . . . . . . . 17ZENZEDI . . . . . . . . . . . . . . . . . 45ZERIT . . . . . . . . . . . . . . . . . . . . 32ZESTORETIC . . . . . . . . . . . . . . 8ZESTRIL . . . . . . . . . . . . . . . . . . . 8ZETIA . . . . . . . . . . . . . . . . . . . . 11ZIAC . . . . . . . . . . . . . . . . . . . . . . 9ZIAGEN . . . . . . . . . . . . . . . . . . 32zidovudine . . . . . . . . . . . . . . . . 32ZINBRYTA . . . . . . . . . . . . . . . . 15zinc . . . . . . . . . . . . . . . . . . .38, 57ziprasidone . . . . . . . . . . . . . . . 48ZITHROMAX . . . . . . . . . . . . . . 29ZOCOR. . . . . . . . . . . . . . . . . . . 11ZOFRAN . . . . . . . . . . . . . . . . . . 26

ZOFRAN ODT . . . . . . . . . . . . . 26ZOHYDRO ER . . . . . . . . . . . . . 14ZOLINZA . . . . . . . . . . . . . . . . . . 4ZOLOFT . . . . . . . . . . . . . . . . . . 42zolpidem . . . . . . . . . . . . . . . . . 43ZOMACTON . . . . . . . . . . . . . . 24ZONEGRAN . . . . . . . . . . . . . . 16zonisamide . . . . . . . . . . . . . . . 16ZORTRESS . . . . . . . . . . . . . . . . 6ZOSTAVAX . . . . . . . . . . . . . . . . 60zoster vaccine live . . . . . . . . . . 60zoster vaccine recombinant

adjuvanted . . . . . . . . . . . . . 60ZOVIA 1/35 . . . . . . . . . . . . . . . 36ZOVIA 1/50 . . . . . . . . . . . . . . . 36ZOVIRAX . . . . . . . . . . . . . . . . . 31ZUBSOLV . . . . . . . . . . . . . . . . . 44ZYBAN . . . . . . . . . . . . . . . . . . . 44ZYDELIG . . . . . . . . . . . . . . . . . . 5ZYKADIA . . . . . . . . . . . . . . . . . . 4ZYLOPRIM . . . . . . . . . . . . . . . . 35ZYPREXA . . . . . . . . . . . . .46, 48ZYPREXA RELPREVV . . . . . . 46ZYPREXA ZYDIS . . . . . . . . . . 46ZYRTEC . . . . . . . . . . . . . . .21, 61ZYRTEC CHEWABLE

TABLET . . . . . . . . . . . . . . . 21ZYRTEC D . . . . . . . . . . . . . . . . 61ZYRTEC-D . . . . . . . . . . . . . . . . 22ZYTIGA . . . . . . . . . . . . . . . . . . . 5ZYVOX . . . . . . . . . . . . . . . . . . . 33

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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 Medicineand Strength

DrugTier

I Take ThisMedicine For Directions Doctor

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

preferred drug list (pdl) - uhccommunityplan.com · some cases your doctor must do something before...

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