preferred drug list (pdl) · this preferred drug list ( pdl) to be used when prescrbi ni g for...

© 2020 United HealthCare Services, Inc. All rights reserved.

Preferred Drug List (PDL)Rhode Island Effective Date: 1/1/20

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

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

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

[email protected]

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

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

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

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

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

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

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

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

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

CSRI15MC4116789_000

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

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

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

[email protected]

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

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

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

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

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

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

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

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

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

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INTRODUCTION UnitedHealthcare Community Plan is pleased to provide this Preferred Drug List (PDL) to be used when prescribing for patients covered by the pharmacy benefit plan offered by UnitedHealthcare Community Plan. This PDL is in compliance with the final and approved legislative action to Article 10, Substitute A as amended which modified Section 40-21-1 of the General Laws in Chapter 40-21 entitled "Medical Assistance - Prescription Drugs”. This action would mandate the dispensing of generic-only drugs with the exception of limited brand drug coverage for certain therapeutic classes as approved by the Department of Human Services. The drugs listed in this PDL are intended to provide sufficient options to treat patients who require treatment with a drug from that pharmacologic or therapeutic class. The drugs listed in the UnitedHealthcare Community Plan PDL have been reviewed and approved by the Pharmacy and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare Community Plan. It is also recognized there may be occasions where an unlisted drug is desired for proper medical management of a specific patient. In those infrequent instances, the unlisted medication may be requested through the prior authorization process. The drugs represented have been reviewed by the Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The PDL is reflective of current medical practice as of the date of review. This edition incorporates drugs added to the PDL since the last edition as well as numerous revisions to the prescribing information based on changes in pharmacotherapy. Comments and suggestions from practicing physicians have also been incorporated to ensure that the UnitedHealthcare Community Plan PDL is reflective of current medical practice. NOTICE The information contained in this PDL and its appendices is provided by UnitedHealthcare Community Plan, solely for

the convenience of medical providers. UnitedHealthcare Community Plan does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This PDL is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs. UnitedHealthcare Community Plan assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information. PREFACE The UnitedHealthcare Community Plan PDL is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. Products are listed by generic name. Brand names are included as a reference to assist in product recognition. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the PDL. Generics should be considered the first line of prescribing. The UnitedHealthcare Community Plan PDL covers selected over-the-counter (OTC) products. You are encouraged to prescribe OTC medications when clinically appropriate. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The P&T Committee includes physicians and pharmacists who are not employees or agents of UnitedHealthcare Community Plan or its affiliates. They must adhere to the Ethics Policy standards of the P&T Committee. UnitedHealthcare Community Plan medical directors and pharmacists also participate in the P&T Committee. The P&T Committee meets quarterly to discuss a variety of issues. Those issues pertaining to pharmaceutical selection and pharmacy program management are communicated quarterly. This newsletter is distributed to all participating

Preferred Drug List

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physicians who have received the PDL. PDL decisions are also communicated quarterly on the UnitedHealthcare Community Plan internet site. OUTPATIENT PRESCRIPTION DRUG BENEFIT-COVERED MEDICATIONS Medically necessary outpatient prescription drugs are covered when prescribed by a provider licensed to prescribe federal legend drugs or medicines. Some items are covered only with prior authorization. Eligibility for Outpatient Prescription Drug Benefits is based on the individual member’s benefit plan. PRODUCT SELECTION CRITERIA The P&T Committee considers clinical information on new-to-market drugs that are typically included in an outpatient pharmacy benefit. The evaluation includes all or part of the following:

• Safety • Efficacy • Comparison studies • Approved indications • Adverse effects • Contraindications/Warnings/Precautions • Pharmacokinetics

• Patient administration/compliance considerations • Medical outcome and pharmacoeconomic studies

When a new drug is considered for PDL inclusion, it will be reviewed relative to similar drugs currently included in the UnitedHealthcare Community Plan PDL. This review process may result in deletion of drug(s) in a particular therapeutic class in an effort to continually promote the most clinically useful and cost-effective agents. All the information in the PDL is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. PDL PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are covered on the PDL, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are covered. Products covered include all strengths associated with the dosage form of the cited brand name product. carvedilol Coreg All strengths of Coreg would be covered by this listing.

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

diltiazem sustained release CARDIZEM SR Dosage forms covered will be consistent with the category and use where listed. Neomycin/polymyxin B/ Cortisporin Hydrocortisone As listed in the OTIC section, this is limited to the otic solution and suspension. From this entry the ophthalmic solution and ointment, and the topical cream cannot be assumed to be on the list unless there are entries for these products in the OPHTHALMIC and DERMATOLOGY sections of the PDL. When a strength or dosage form is specified, only the specified strength and dosage form is on the PDL. Other strengths/dosage forms of the reference product are not citalopram 40 mg tabs Celexa tabs DRUG TIERS The drugs listed in the PDL have different tiers. The tiers are listed in the grid below.

Tier Name Drug Tier Tier 1 Generic Tier 2 Brand

GENERIC SUBSTITUTION The UnitedHealthcare Community Plan PDL requires generic substitution on the majority of products when a generic equivalent is available. Generic substitution is a pharmacy action whereby a generic equivalent is dispensed rather than the brand name product. The PDL indicates generic availability in the “Covered Drug” column. If a brand name drug from another category is medically necessary, please submit a prior authorization request. The UnitedHealthcare Community Plan MAC list sets a ceiling price for the reimbursement of certain multisource prescription drugs. This price will typically cover the acquisition of most generics but not branded versions of the same drug. The products selected for inclusion on the MAC list are commonly prescribed and dispensed and have usually gone through the FDA’s review and approval process.

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An important consideration for generic substitution is the knowledge that all approvals of generic drugs by the FDA since 1984, and many generic approvals prior to 1984, have a showing of bioequivalence between the generic versions and the reference brand product. To gain FDA approval: 1. The generic drug must contain the same active ingredient(s), be the same strength and the same dosage form as the brand name product 2. The FDA has given the generic an “A” rating compared

to the branded product indicating bioequivalence, and has determined the generic is therapeutically equivalent to the reference brand. The ratings of generic drugs are available by referring to the FDA reference, Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book).

When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent generic drug product is substituted for the brand name product. There are now many brand name products that are repackaged or distributed under a generic label. The generic label version should always be considered therapeutically equivalent and substitutable for the source branded product. DRUG EFFICACY STUDY IMPLEMENTATION (DESI) DRUGS Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from 1938-1962. The DESI program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of “fully effective” was made for most of these products and they remain in the marketplace. A few DESI products remain classified as “less than fully effective” while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. United’s PDL does not cover DESI “less than fully effective” drug products.

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

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

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

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

DAYS SUPPLY DISPENSING LIMITATIONS UnitedHealthcare Community Plan members may receive up to a one- month supply of a specific medication per prescription order or prescription refill. A medication may be reordered or refilled when ninety percent (90%) of the medication has been utilized for a controlled substance and eighty-five percent (85%) of the medication has been utilized for a non-controlled substance. If a claim is submitted before 90% of the medication has been used for a controlled substance or submitted before 85% of the medication has been used for a non-controlled substance, based on the original day supply submitted on the claim, the claim will reject with a “refill too soon” message. MANDATORY GENERIC SUBSTITUTION The UnitedHealthcare Community Plan PDL requires mandatory generic substitution on the vast majority of products when a generic equivalent is available; however, brand name drugs may be covered in certain situations by requesting a prior authorization. The UnitedHealthcare Community Plan PDL prior authorization (PA) list does not include branded items where a generic equivalent is covered. PRIOR AUTHORIZATION OF NON-PDL MEDICATIONS The drugs in the UnitedHealthcare Community Plan PDL have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare Community Plan. It is also recognized that there may be occasions where an unlisted drug is

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desired for the proper medical management of a specific patient. In those infrequent instances, the prior authorization process reviews requests for unlisted medications the physician may consider medically necessary for patient management. Requests for these exceptions should be made in writing by the physician and faxed to:

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

A prior authorization request form is available in the UnitedHealthcare Community Plan provider manual and should be used for all prior authorization requests if possible. Appropriate documentation must be provided to support the medical necessity of the non-PDL request. The UnitedHealthcare Community Plan Pharmacy Department will respond to all requests in accordance with state requirements. Physicians are requested to adhere to this PDL when prescribing for patients covered by their pharmacy benefit plan offered by UnitedHealthcare Community Plan. If a pharmacist receives a prescription for a non-PDL drug, the pharmacist should contact the prescribing physician and request that the prescription be changed to a medication included in this PDL. If a PDL alternative is not appropriate the physician should then be instructed to contact the Plan for a prior authorization. Please contact the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826 with questions concerning the prior authorization process. PRIOR AUTHORIZATION OF EXCLUDED BRAND MEDICATIONS It is also recognized that there may be occasions where an excluded brand drug is desired for the proper medical management of a specific patient. In those infrequent instances, the prior authorization process reviews requests for these medications the physician may consider medically necessary for patient management. Requests for these exceptions should be made in writing by the physician and faxed to:

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

NON-PDL DRUGS 5-DAY OVERRIDES To ensure the use of PDL drugs, all non-PDL drugs should be discussed with the prescribing physician. If you cannot speak to the physician immediately, and there is an immediate need for the medication, the claim processing

system will accept an override to permit a one-time dispensing of a 5-day supply of the newly prescribed non-PDL drug. The pharmacy should submit a claim for a 5 day supply, with a PA Type of 8 and Prior Authorization number of “00000000120”. Please note that non-preferred drugs are available for a 5-day supply, however availability is subject to the benefit design. For assistance, pharmacies may call 800-310-6826. PRIOR AUTHORIZATION REQUIRED. CALL DOCTOR FOR ALTERNATIVE. MAY SUB OVER 5 DS. QUANTITY LIMITATIONS (QL) Prescriptions for monthly quantities greater than the indicated limit require a prior authorization request. Quantity limits based on Efficient Medication Dosing The Efficient Medication Dosing Program is designed to consolidate medication dosage to the most efficient daily quantity to increase adherence to therapy and also promote the efficient use of health care dollars. The limits for the program are established based on FDA approval for dosing and the availability of the total daily dose in the least amount of tablets or capsules daily. Quantity Limits in the prescription claims processing system will limit the dispensing to consolidate dosing. The pharmacy claims processing system will prompt the pharmacist to request a new prescription order from the physician. Additions to the QL program drug list will be made from time to time and providers notified accordingly. As always, we recognize that a number of patient-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the medical exception (prior authorization) process. Please contact the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826 with questions. Specialty Pharmaceutical Management Program UnitedHealthcare Community Plan is continuously looking for ways to provide high quality cost effective care for Plan members. The Specialty Pharmaceutical Management Program helps UnitedHealthcare Community Plan to achieve these goals. Injectable medications that are part of this program require plan authorization and are not available through the retail pharmacy network. To obtain authorization, the provider must submit the appropriate Prior Authorization form to the UnitedHealthcare Community Plan Pharmacy Department via fax at 866-940-7328. The UnitedHealthcare Community Plan Pharmacy Department will review and respond to all requests in accordance with state requirements, and if authorized for payment, UnitedHealthcare Community Plan will coordinate the delivery of the product to the member or provider.

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Drugs that are part of this program and are on the PDL are identified in this booklet by the designation "SP". Prior Authorization request forms can be requested by calling the UnitedHealthcare Community Plan Pharmacy Department at 800-310-6826. MEDICATIONS REQUIRING DIAGNOSIS UnitedHealthcare Community Plan requires that the diagnosis for prescriptions in certain classes match the FDA-approved use or a use supported by current published evidence. Drugs in scope will list “Diagnosis required” in the Requirements and Limits or with the drug class name on the PDL. The diagnosis will be verified at the point-of-sale by the pharmacy claims processing system. If a matching diagnosis is not found in the medical claim file or on the pharmacy drug claim, the prescription will be rejected at the pharmacy. The pharmacist may then contact the prescriber to verify the diagnosis and submit it on the claim. If the diagnosis provided still does not match the approved use, prior authorization may be requested through the standard process by faxing a request to 866-940-7328. Gender dysphoria benefits Drug therapy for gender Dysphoria is a covered benefit for UnitedHealthcare Community Plan members. For members with a Gender Dysphoria diagnosis requiring higher than the FDA approved dose can get their medications by providing the appropriate diagnosis at point of sale. The diagnosis will be verified at the point-of-sale by the pharmacy claims processing system The pharmacist may contact the prescriber to verify the diagnosis and submit it on the claim. If the diagnosis provided does not match the approved use, prior authorization may be requested through the standard process by faxing a request to 866-940-7328. STEP THERAPY (ST) The following PDL drugs are routinely covered only after a sufficient trial of an indicated first-line agent has been adequately tried and failed. These medications may also be requested through the Prior authorization process. While lower cost PDL alternatives may be appropriate in many instances, other non- PDL alternatives are available with prior authorization (PA). STEP Drug First-Line Agent(s) Amerge Trial at a minimum dose of 50mg of

sumatriptan tablets. Aricept 23mg 90 day trial of Aricept 10mg daily calcipotriene Trial of two medium to high potency cream & oint corticosteroids 0.005%

calcitriol Trial of two medium to high potency 3mcg/gm corticosteroids DPP4 Inhibitors At least a 90 day trial of 1500mg/day of (Nesina, metformin. Kazano, Oseni) Elidel Minimum age of 2. Trial of two generic

topical corticosteroids. fenofibrate Fill of a statin or 90 days of gemfibrozil

within the previous 180 days. GLP-1 Agonists At least a 90 day trial of 1500mg/day of (Victoza metformin 2 pen pack) IBS Trial of two first line generics (Lactulose Constipation and/or polyethylene glycol) Agents (Linzess, Movantik, Trulance) Optivar 14 day trial of ketotifen within previous

90 days required first. Ranexa Trial of two generic drugs from the

following classes: beta blockers, calcium channel blockers, long acting nitrates

Renvela 8 week trial of calcium acetate tacrolimus 0.03% Minimum age of 2.Trial of two

topical corticosteroids. tacrolimus 0.1% Minimum age of 16. Trial of two

topical corticosteroids. tolterodine 30 day trial of oxybutynin immediate or

extended release. Step Therapy only applies to members less than 65 years of age.

tretinoin Cream Trial of Differin OTC Gel 0.1%. (tretinoin cream 0.025%, 0.05%, 0.1%, and Avita cream 0.025%) trospium 30 day trial of oxybutynin immediate or

extended release. Step Therapy only applies to members less than 65 years of age.

Uloric 8 week trial of up to 600mg of

allopurinol required first. Xopenex Respules 30 day trial of Albuterol .083% or .5%

respules.

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

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

Providers should furnish adequate documentation, such as clinical studies from the medical literature, in order for the request to be considered for PDL addition. This literature should include information documenting clinical necessity as well as therapeutic advantages over current PDL products. Suggestions received by UnitedHealthcare Community Plan will be reviewed by the Pharmacy and Therapeutics Committee at the subsequent P&T Committee meeting. EDITOR Your comments and suggestions regarding the UnitedHealthcare Community Plan PDL are encouraged. Your input is vital to this PDL’s continued success. All responses will be reviewed and considered. Please send your comments to:

UnitedHealthcare Community Plan Director of Pharmacy Services

2 Allegheny Center Suite 600 Pittsburgh, PA 15212 Phone: 800-310-6826

LEGEND # Only the dosage forms/strengths of the brand

name products noted are on the PDL OTC over-the-counter delayed-rel delayed-release (also known as enteric coated) EC enteric-coated ext-rel extended-release (also known as sustained-

release) PA Prior Authorization required QL Quantity Limits apply ST Step Therapy, see pages V for details SP Specialty Pharmaceuticals, see pages IV-V for details NOTICE The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of UnitedHealthcare Community Plan. All rights reserved. The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with UnitedHealthcare Community Plan. These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between UnitedHealthcare Community Plan and such third-party pharmaceutical companies. If viewing this PDL via the Internet, please be advised that the PDL is updated periodically and changes may appear prior to their effective date to allow for notification.

mailto:[email protected]

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

Blood Modifiers - Anticoagulants . . . . . . . . . 7Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Hematopoietic Agents. . . . . . . . . . . . . . . . . . . . . . 7Platelet Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . 7Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

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

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

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

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

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

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

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

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

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

3

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

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

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

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

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

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

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

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

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

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

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

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

4

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

ST = Step TherapySP = Specialty Pharmacy

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

Antineoplastics & Immunosuppressants

Antineoplastic AgentsAlkylating Agentsaltretamine HEXALEN brand 2busulfan MYLERAN brand 2chlorambucil LEUKERAN brand 2cyclophosphamide CYTOXAN generic 1lomustine GLEOSTINE brand 2melphalan ALKERAN brand 2temozolomide TEMODAR generic 1 PA, SPAntimetabolitescapecitabine XELODA generic 1 SPmercaptopurine PURINETHOL generic 1thioguanine TABLOID brand 2trifluridine/tipiracil LONSURF brand 2 PA, SPHistone Deacetylase Inhibitorspanobinostat FARYDAK brand 2 PA, SPvorinostat ZOLINZA brand 2 PA, SPIsocitrate Dehydrogenase (IDH) Inhibitorsenasidenib IDHIFA brand 2 PA, QL, SPivosidenib TIBSOVO brand 2 PA, QL, SPKinase Inhibitorabemaciclib VERZENIO brand 2 PA, QL, SPacalabrutinib CALQUENCE brand 2 PA, QL, SPafatinib GILOTRIF brand 2 PA, SPalectinib ALECENSA brand 2 PA, SPalpelisib PIQRAY brand 2 PA, QL, SPaxitinib INLYTA brand 2 PA, SPbosutinib BOSULIF brand 2 PA, SPbrigatinib ALUNBRIG brand 2 PA, SPcabozantinib COMETRIQ brand 2 PA, SPcabozantinib CABOMETYX brand 2 PA, SPceritinib ZYKADIA brand 2 PA, SPcobimetinib COTELLIC brand 2 PA, SPcrizotinib XALKORI brand 2 PA, SPdabrafenib TAFINLAR brand 2 PA, SPdasatinib SPRYCEL brand 2 PA, SPerdafitinib BALVERSA brand 2 PA, QL, SPerlotinib TARCEVA brand 2 PA, SP

everolimusAFINITORAFINITOR DISPERZ

brand 2 PA, SP

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

5




idelalisib ZYDELIG brand 2 PA, SPimatinib mesylate GLEEVEC generic 1 PA, QL, SPlapatinib ditosylate TYKERB brand 2 PA, SPlarotrectinib VITRAKVI brand 2 PA, QL, SPlenvatinib LENVIMA brand 2 PA, SPmidostaurin RYDAPT brand 2 PA, SPnilotinib TASIGNA brand 2 PA, SPpalbociclib IBRANCE brand 2 PA, SPpazopanib VOTRIENT brand 2 PA, SPponatinib ICLUSIG brand 2 PA, SPregorafenib STIVARGA brand 2 PA, SPruxolitinib JAKAFI brand 2 PA, SPsorafenib NEXAVAR brand 2 PA, SPsunitinib SUTENT brand 2 PA, SPtrametinib MEKINIST brand 2 PA, SPvandetanib CAPRELSA brand 2 PA, SPvemurafenib ZELBORAF brand 2 PA, SPMiscellaneousleucovorin LEUCOVORIN generic 1 QL, tabsmesna MESNEX brand 2 SP, tabletsvenetoclax VENCLEXTA brand 2 PA, SPProteasome Inhibitorsixazomib NINLARO brand 2 PA, SPHormonal Antineoplastic AgentsAndrogen Biosynthesis Inhibitors

abiraterone ZYTIGA generic 1 PA, SP, 250 mg tablets only

Antiandrogensapalutamide ERLEADA brand 2 PA, QL, SPbicalutamide 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 2 PA, SPthalidomide THALOMID brand 2 PA, SPImmunosuppressantsAntimetabolitesazathioprine IMURAN generic 1mycophenolate mofetil CELLCEPT generic 1mycophenolate sodium MYFORTIC generic 1Calcineurin Inhibitorscyclosporine SANDIMMUNE generic 1cyclosporine, modified NEORAL generic caps, QL

tacrolimusHECORIA PROGRAF

generic 1

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

topical gel TARGRETIN brand PA, SP

cysteamine bitartrate CYSTAGON brand 2 SPetoposide VEPESID generic 1glasdegib DAURISMO brand 2 PA, QL, SPhydroxyurea DROXIA brand 2hydroxyurea HYDREA generic 1leuprolide LEUPROLIDE ACETATE generic 1 PA, SPmesna MESNEX brand 2mitotane LYSODREN brand 2niraparib ZEJULA brand 2 PA, SPoctreotide SANDOSTATIN generic 1 SPolaparib LYNPARZA brand 2 PA, SPpasireotide SIGNIFOR brand 2 PA, SP

7




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

Blood Modifiers - Anticoagulants

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

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

warfarin COUMADIN generic 1Hematopoietic Agentsdarbepoetin alfa ARANESP brand 2 PA, QL, SPeltrombopag PROMACTA brand 2 PA, QL, SPepoetin alfa-epbx RETACRIT brand 2 PA, SPfilgrastim ZARXIO brand 2 PA, SPlusutrombopag MULPLETA brand 2 PA, QL, SPoprelvekin NEUMEGA brand 2 PA, SPpegfilgrastim NEULASTA brand 2 PA, SPplerixafor MOZOBIL brand 2 PA, SPsargramostim LEUKINE brand 2 PA, SPPlatelet Inhibitorsanagrelide AGRYLIN generic 1

aspirin BAYERECOTRIN generic 1 OTC

cilostazol PLETAL generic 1clopidogrel PLAVIX generic 1 QLdipyridamole PERSANTINE generic 1prasugrel EFFIENT generic 1 Diagnosis Required, QLMiscellaneousaminocaproic acid AMICAR generic 1 tabs, QLcaplacizumab-yhdp CABLIVI brand 2 PA, QL, SP

deferasirox EXJADEJADENU brand 2 PA, SP

emicizumab-kxwh HEMLIBRA brand 2 PA, QL, SPpentoxifylline

extended-release TRENTAL generic 1

8




Cardiovascular Agents

Ace Inhibitorsbenazepril LOTENSIN generic 1captopril CAPOTEN generic 1enalapril VASOTEC generic 1fosinopril MONOPRIL generic 1 QLlisinopril ZESTRIL generic 1 QLquinapril ACCUPRIL generic 1 QLramipril ALTACE generic 1trandolapril MAVIK generic 1Ace Inhibitor/Diuretic Combinationsbenazepril/

hydrochlorothiazide LOTENSIN HCT generic 1

captopril/ hydrochlorothiazide CAPOZIDE generic 1

enalapril/ hydrochlorothiazide VASERETIC generic 1

fosinopril/ hydrochlorothiazide MONOPRIL-HCT generic 1 QL

lisinopril/ hydrochlorothiazide ZESTORETIC generic 1 QL

quinapril/ hydrochlorothiazide ACCURETIC generic 1 QL

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

9




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

extended-releaseQUINIDINE GLUCONATE

EXT-REL generic 1

quinidine sulfate QUINIDINE SULFATE generic 1quinidine sulfate

extended-releaseQUINIDINE SULFATE

EXT-REL generic 1

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

hydrochlorothiazide ZIAC generic 1

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

extended-release PLENDIL generic 1 QL

nifedipine PROCARDIA generic 1nifedipine extended-

releaseADALAT CCPROCARDIA XL

generic 1 QL

nimodipine NIMOTOP generic 1 QL

10




Nondihydropyridinesdiltiazem CARDIZEM generic 1diltiazem

extended-release CARDIZEM CD generic 1 QL

diltiazem extended-release

DILACOR XR TIAZAC

generic 1 QL

diltiazem sustained-release CARDIZEM SR generic 1 QL

verapamil CALAN generic 1verapamil

extended-release CALAN SR generic 1 QL

Diureticsamiloride MIDAMOR generic 1amiloride/

hydrochlorothiazide MODURETIC generic 1

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

hydrochlorothiazide ALDACTAZIDE generic 1

torsemide DEMADEX generic 1triamterene/

hydrochlorothiazideDYAZIDEMAXZIDE

generic 1

Lipid Lowering AgentsBile Acid Resin

cholestyramineQUESTRANQUESTRAN-LIGHT

generic 1

Only the bulk products are covered (cans).

Individual packets are not covered.

Fibratesfenofibrate LOFIBRA generic 1 STgemfibrozil LOPID generic 1

11




HMG-CoA Reductase Inhibitors and Combinationsatorvastatin LIPITOR generic 1 QLlovastatin MEVACOR generic 1 QLsimvastatin ZOCOR generic 1 QLNiacinsniacin NIACOR generic 1niacin extended-release NIASPAN generic 1Miscellaneous

alirocumab PRALUENT brand 2 PA, QL, SP, NDC starting w/72733 pref w/PA

evolocumab REPATHA brand 2 PA, QL, SP, NDC starting w/72511 pref w/PA

ezetimibe ZETIA generic 1 PAomega 3 acid ethyl esters LOVAZA generic 1 PANitratesOralisosorbide dinitrate ISORDIL generic 1isosorbide dinitrate

extended-releaseISOSORBIDE

DINITRATE ER generic 1

isosorbide mononitrate ISMO generic 1isosorbide mononitrate

extended-release IMDUR generic 1

Sublingualnitroglycerin NITROSTAT generic 1Transdermalnitroglycerin NITRO-DUR generic 1 transdermal, QL Potassium-Removing Agentspatiromer VELTASSA brand 2 PA, QLsodium polystyrene

sulfonate KAYEXALATE generic 1 susp (susp only)

sodium zirconium cyclosilicate LOKELMA brand 2 PA, QL

Pulmonary Arterial Hypertension - Diagnosis Requiredambrisentan LETAIRIS generic 1 QL, SPbosentan TRACLEER brand 2 QL, SPmacitentan OPSUMIT brand 2 QL, SPriociguat ADEMPAS brand 2 QL, SPsildenafil REVATIO generic 1 QL, SP, tabletsMiscellaneousguanabenz WYTENSIN generic 1hydralazine APRESOLINE generic 1methyldopa ALDOMET generic 1midodrine PROAMATINE generic 1

12




minoxidil LONITEN generic 1ranolazine RANEXA generic 1 QL, STtafamidis VYNDAMAX brand 2 PA, QL, SPtafamidis meglumine VYNDAQEL brand 2 PA, QL, SP

Central Nervous System

Alzheimer’s Disease

donepezil ARICEPT generic 1

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

authorization.

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

prior authorization.

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

authorization.

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

authorization.

rivastigmineEXELON TABSEXELON PATCH

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

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

caffeineESGICZEBUTAL

generic 1 QL

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

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

tramadol ULTRAM generic 1 QLNSAIDSdiclofenac potassium CATAFLAM generic 1diclofenac sodium

delayed-release VOLTAREN generic 1

diclofenac sodium extended-release VOLTAREN XR generic 1

etodolac LODINE generic 1 IR Only

13




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

ibuprofen MOTRIN generic 1 tabs, chew tabs and suspindomethacin INDOCIN generic 1ketoprofen ORUDIS generic 1 IR onlyketorolac tromethamine TORADOL generic 1 QLmeloxicam MOBIC generic 1 QLnabumetone RELAFEN generic 1naproxen NAPROSYN generic 1

naproxen delayed release ENTERIC COATED-NAPROSYN generic 1

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

hydrocodone/ acetaminophen

LORCETLORTABLORTAB ELIXIRNORCOVICODINVICODIN ES

generic 1 QL

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

extended-release MS CONTIN generic 1 PA, QL

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

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

oxycodone/aspirin PERCODAN generic 1 QL

14




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

pentazocine/naloxone TALWIN NX generic 1 QLMigraine Acute TherapyErgotamine Derivativesdihydroergotamine D.H.E. 45 generic 1 inj, QLergotamine/caffeine CAFERGOT generic 1Selective Serotonin Agonistsnaratriptan AMERGE generic 1 ST

rizatriptanMAXALTMAXALT MLT

generic 1 QL

sumatriptan IMITREX generic 1 QL

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

Migraine Prophylactic Therapyamitriptyline ELAVIL generic 1

divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1

Members ≥ 8 years of age will require prior

authorization.divalproex sodium

delayed-release DEPAKOTE generic 1 Minimum age 2

erenumab-aooe AIMOVIG brand 2 PA, QLgalcanezumab-gnim EMGALITY brand 2 PA, QLpropranolol INDERAL generic 1 IR onlyverapamil CALAN generic 1Multiple Sclerosis - Diagnosis Requireddimethyl fumarate TECFIDERA brand 2 QL, SPfingolimod GILENYA brand 2 QL, SPglatiramer acetate COPAXONE generic 1 QL, SPpeginterferon beta-1a PLEGRIDY brand 2 QL, SPsiponimod fumarate MAYZENT brand 2 PA, QL, SPteriflunomide AUBAGIO brand 2 QL, SPMyasthenia Gravispyridostigmine MESTINON generic 1pyridostigmine extended-

release MESTINON TIMESPAN generic 1

15




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

extended-release SINEMET CR generic 1

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

extended-releaseCARBATROLTEGRETOL-XR generic 1

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

divalproex sodium cap sprinkle DEPAKOTE SPRINKLE generic 1


authorization. divalproex sodium


ethosuximide ZARONTIN generic 1felbamate FELBATOL generic 1 QL, tablets

felbamate oral susp FELBATOL generic 1

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

authorization. gabapentin NEURONTIN generic 1 caps and tabs 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 generic 1

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

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

16




phenobarbital PHENOBARBITAL generic 1phenytoin DILANTIN INFATABS generic 1phenytoin sodium

extendedDILANTINPHENYTEK

generic 1

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

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

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

topiramate TOPAMAX generic 1 QL

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

authorization.valproic acid DEPAKENE generic 1vigabatrin powd pack SABRIL generic 1 PA, SPzonisamide ZONEGRAN generic 1 QLMiscellaneousinotersen inj TEGSEDI brand 2 PA, QL, SP

tetrabenazine XENAZINE generic 1 Diagnosis Required, QL, SP

valbenazine INGREZZA brand 2 PA, QL, SP

Dermatology

Acne VulgarisOral

isotretinoin

AMNESTEEMCLARAVISMYORISANZENTANE

generic 1 PA

Topicaladapalene gel DIFFERIN OTC GEL 0.1% brand 2azelaic acid FINACEA generic 1 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

17




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

sulfacetamide/sulfur SULFACET-R generic 1 lotionsulfacetamide/sulfur SUMADAN WASH generic 1

tretinoinAVITA RETIN-A

generic 1 cream, ST

Bacterial Infectionsbacitracin BACITRACIN generic 1 OTCgentamicin GENTAK generic 1

mupirocin BACTROBAN generic 1 ointment, 22 gram tube only

neomycin/polymyxin B/bacitracin NEOSPORIN generic 1 OTC

silver sulfadiazine SILVADENE generic 1CorticosteroidsLow Potencyalclometasone ACLOVATE generic 1 0.05% oint

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

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

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

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

augmented dip DIPROLENE generic 1 lotion 0.05%

betamethasone augmented dip DIPROLENE AF generic 1 crm 0.05%

18




betamethasone dipropionate generic 1 lotion/oint 0.05%

fluocinonide LIDEX generic 1 soln 0.05%fluocinonide emulsified

base LIDEX E generic 1 crm 0.05%

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

augmented DIPROLENE generic 1 gel 0.05%

betamethasone dip augmented DIPROLENE generic 1 oint 0.05%

clobetasol propionate TEMOVATE generic 1 soln 0.05%clobetasol propionate

emollient base cream TEMOVATE E generic 1 QL

halobetasol ULTRAVATE generic 1 creamFungal Infectionsciclopirox PENLAC SOLUTION 8% generic 1clotrimazole LOTRIMIN AF generic 1 OTCclotrimazole MYCELEX generic 1clotrimazole with

betamethasone LOTRISONE generic 1

ketoconazole NIZORAL generic 1miconazole DESENEX generic 1 2% OTCmiconazole MICATIN generic 1 OTCmiconazole MONISTAT-DERM generic 1nystatin MYCOSTATIN generic 1terbinafine LAMISIL AT generic 1 OTCtolnaftate TINACTIN generic 1 OTCPsoriasis acitretin SORIATANE generic 1 oral caps, PAcalcipotriene DOVONEX generic 1 crm/oint, STcalcipotriene DOVONEX generic 1 solncalcitriol VECTICAL generic 1 ST

salicylic acidCOMPOUND W DUOFILM

generic 1 liquid 17%

salicylic acid SCALPICIN generic 1 liquid 3%Rosacea

metronidazoleMETROCREAMMETROGEL

generic 1

metronidazole METROLOTION generic 1 QL

19




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

butoxide shampoo RID SHAMPOO generic 1 4% OTC

spinosad NATROBA generic 1 QLViral Infectionspodofilox CONDYLOX SOL generic 1Miscellaneousaluminum acetate brand 2 soln/cream, OTC

ammonium lactateAMLACTIN LAC-HYDRIN

generic 1 crm 12%, lotion 5% & 12%

ammonium lactate LACTINOL generic 1 lotion 10%becaplermin gel REGRANEX brand 2 Diagnosis Required, QLcalamine brand 2 lotion/ointment, OTCchloroxine CAPITROL generic 1

emollientsE-OINTMENTDERMAPHOR OINTMENTGLYCERIN TOPICAL

brand 2

fluorouracil EFUDEX generic 1

hydrocortisone

PROCTOSOL HC CREAM 2.5%

PROCTOZONE CREAM-HC 2.5%

ANUSOL HC 2.5%

generic 1

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

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

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

pimecrolimus ELIDEL generic 1

cream, QL, ST, not covered

for members less than2 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

20




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

urea 40% UREA 40% LOTION generic 1 lotion

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

brand 2

Ear, Nose & Throat

Earacetic acid VOSOL OTIC generic 1 oticacetic acid/

aluminum acetate DOMEBORO OTIC generic 1

acetic acid/ hydrocortisone VOSOL HC OTIC generic 1

benzocaine/antipyrine BENZOTIC generic 1carbamide peroxide DEBROX generic 6.5%, OTCneomycin/polymyxin B/

hydrocortisone CORTISPORIN OTIC generic 1 otic

ofloxacin FLOXIN OTIC generic 1NoseAntihistamines - First Generation, Sedatingchlorpheniramine

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

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

cetirizine chew tab ZYRTEC CHEWABLE TABLET generic 1

OTC, Members ≥ 8 years of age will require prior

authorization.levocetirizine XYZAL generic 1 tabsloratadine ALAVERT-D generic OTCAntihistamine - Others Antihistamine/Decongestant Combinationsazelastine ASTELIN NASAL SPRAY 0.1% generic 1 QLNasal Steroidsfluticasone FLONASE generic 1

triamcinolone nasal spray NASACORT ALLERGY 24 HOUR brand 2 OTC

21




Miscellaneous Nasal Decongestantsoxymetazoline AFRIN generic 1 OTC

phenylephrineNEO-SYNEPHRINE DIMEATAPP DRO

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 1fludrocortisone FLORINEF generic 1hydrocortisone CORTEF generic 1methylprednisolone MEDROL generic 1 4mg, 8mg, 16mg, 32mgprednisolone PRELONE generic 1 syrupprednisolone MILLIPRED brand 2 tabletsdiphenhydramine BENADRYL generic 1 OTCprednisolone sodium

phosphateORAPREDPEDIAPRED

generic 1

prednisone DELTASONE generic 1Androgenstestosterone cypionate DEPO-TESTOSTERONE generic 1

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

testosterone gel topical tube, packet, and pump bottle

TESTOSTERONE 1% TOPI-CAL GEL generic 1 PA

Diabetes MellitusGlucose Elevating Agentsglucagon, human

recombinant GLUCAGON brand 2 QL

Insulin Combinationsinsulin glargine/lixisenatide SOLIQUA brand 2 QL, ST

22




Insulinsinsulin aspart

protamine 70%/ insulin aspart 30%

NOVOLOG MIX 70/30 brand 2 QL, vials

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

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

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

insulin isophane/regular HUMULIN 70/30 brand 2 OTC, QL, vialsinsulin lisopro pro/lispro HUMALOG MIX 50/50 brand 2 QL, vialsinsulin lisopro prot/lispro HUMALOG MIX 75/25 brand 2 QL, vialsinsulin lispro ADMELOG SOLOSTAR brand 2 PA, QLinsulin lispro ADMELOG VIALS brand 2 QLinsulin regular HUMULIN R brand 2 OTC, QL, U-100 vialsMiscellaneous Antidiabetic Agentsdulaglutide TRULICITY brand 2 QL, PAliraglutide VICTOZA 2 PEN PACK brand 2 QL, STlixisenatide ADLYXIN brand 2 PAMonitoring - Strips and Kits/Diabetic Supplies

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

QL for insulin dependent or pregnant members:

allow testing up to 6 times per day

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

dependent members: allow twice daily testing

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

23




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

nitisinone NITYR brand 2 Diagnosis Required, QL, SP

pegvisomant SOMAVERT brand 2 PA, QL, SP

sapropterin KUVAN brand 2 Diagnosis Required, QL, SP

24




sapropterin powder KUVAN POWDER FOR SOLUTION

Diagnosis Required, QL, SP

uridine VISTOGARD brand 2

Gastrointestinal

Constipation/Laxativescasanthranol-docusate

sodium generic 1 OTC

docusate calcium plus generic 1 OTCdocusate potasssium generic 1 OTCdocusate sodium COLACE generic 1 OTCglycerin GLYCERIN SUPPOSITORY generic 1 suppository, OTClactulose ENULOSE generic 1

magnesium citrate soln MAGNESIUM CITRATE SOLN generic 1

naloxegol MOVANTIK brand 2 Diagnosis Required, QL, ST

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

plecanatide TRULANCE brand 2 Diagnosis Required, STpolyethylene glycol 3350 MIRALAX generic 1 ONLY powder bottleprucalopride MOTEGRITY brand 2 Diagnosis Required, QLsennosides SENOKOT generic 1 8.6 mg tab, OTCDiarrheacrofelemer MYTESI brand 2 Diagnosis Required, QLdiphenoxylate/atropine LOMOTIL generic 1loperamide IMODIUM A-D generic 1 OTCloperamide LOPERAMIDE generic 1Emesisaprepitant EMEND generic 1 QL applies to 40mg,

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

ondansetronZOFRANZOFRAN ODT

generic 1 QL

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

25




Gastroesophageal Reflux Disease (Gerd)/Peptic Ulcersalginic acid/sodium

bicarbonate brand 2 OTC

alumina/magnesia MAALOX generic 1 OTCalumina/magnesia/

simethicone MYLANTA generic 1 OTC

cimetidine TAGAMET generic 1

esomeprazole NEXIUM 24HR OTC generic/brand 1/2 PA, QL, OTC

esomeprazole granules NEXIUM DELAYED RELEASE PACKET brand 2

Members ≥ 2 yearsof age will require prior

authorization.

famotidinePEPCIDPEPCID AC

generic 1

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

prescription.lansoprazole PREVACID generic 1

lansoprazole delayed-release PREVACID SOLUTAB generic 1

orally disintegrating tabs, Members ≥ 2 years of age will require prior

authorization, QLomeprazole

delayed-release PRILOSEC generic 1 Capsules only, QL

pantoprazole PROTONIX generic 1ranitidine ZANTAC generic 1 150 mg tabsranitidine syrup ZANTAC generic 1sodium bicarbonate generic 1 tabletssucralfate CARAFATE generic 1

sulcralfate CARAFATE SUSPENSION brand 2

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

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

extended-release LEVSINEX generic 1

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

extended-release DELZICOL generic 1 QL

26




mesalamine supp CANASA generic 1sulfasalazine AZULFIDINE generic 1sulfasalazine

delayed-release AZULFIDINE EN-TABS generic 1

Pancreatic Enzymes

pancrelipaseCREONCREON 3000 UNIT

brand 2 QL

Probiotic Supplementationacidophilus ACIDOPHILUS brand 2 caps and tabs, OTC

acidophilus/bifidus ACIDOPHILUS/ BIFIDUS WAFER brand 2 OTC

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

acidophilus/pectin ACIDOPHILUS/PECTIN brand 2 caps, OTC

probiotics

ALIGNBACIDBIOGAIACULTURELLEDIGESTIVE PROBIOTICFLORAJENFLORANEXFLORASTORLACTINEXPHILLIPS COLON HEALTHRISA-BIDRISAQUAD

brand 2 OTC

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

Infectious Diseases

Anthelminticsalbendazole ALBENZA generic 1 Diagnosis Required, QLivermectin STROMECTOL generic 1praziquantel BILTRICIDE brand 2 Diagnosis Required, QL

27




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

pyrantel pamoate PIN-X brand 2 chewable tablets, suspension

AntibacterialsAntituberculosis Agentsethambutol MYAMBUTOL generic 1isoniazid ISONIAZID generic 1pyrazinamide PYRAZINAMIDE generic 1rifampin RIFADIN generic 1Cephalosporins - First Generationcefadroxil DURICEF generic 1cephalexin KEFLEX generic 1 tabs are not coveredCephalosporins - Second Generationcefaclor CECLOR generic 1cefprozil CEFZIL generic 1cefuroxime axetil CEFTIN generic 1 tabsCephalosporins - Third Generationcefdinir OMNICEF generic 1Fluoroquinolonesciprofloxacin CIPRO generic 1levofloxacin LEVAQUIN generic 1 tablets onlyofloxacin FLOXIN generic 1 tabsMacrolidesazithromycin ZITHROMAX generic 1 QLclarithromycin BIAXIN generic 1clarithromycin ER BIAXIN XL generic 1erythromycin

delayed-release ERYC generic 1

erythromycin ethylsuccinate

E.E.S. ERYPED

generic 1

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

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

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

28




Sulfonamidessulfamethoxazole/

trimethoprim, DSBACTRIMBACTRIM DS

generic 1

Tetracyclines

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

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

omadacycline NUZYRA brand 2 PA, QLMiscellaneousvancomycin powder for

oral solution FIRVANQ brand 2 Diagnosis Required, QL

Antifungalsclotrimazole MYCELEX generic 1 trochesfluconazole DIFLUCAN generic 1 QLgriseofulvin microsize GRIFULVIN V generic 1griseofulvin ultramicrosize GRIS-PEG generic 1itraconazole SPORANOX generic 1 PA, QLketoconazole NIZORAL generic 1nystatin MYCOSTATIN generic 1terbinafine LAMISIL generic 1 QLvoriconazole VFEND generic 1 PA, tabletsAntiprotozoalsatovaquone MEPRON generic 1 PAbenznidazole BENZNIDAZOLE brand 2 Diagnosis Required, QLmiltefosine IMPAVIDO brand 2 PAnitazoxanide tablet ALINIA brand 2 Diagnosis Required, QLpentamidine isethionate

for nebulization NEBUPENT brand 2

Antituberculosis Agentscycloserine SEROMYCIN generic 1rifabutin MYCOBUTIN generic 1 QLAntiviralsCytomegalovirus Treatmentganciclovir CYTOVENE generic 1valganciclovir VALCYTE generic 1 tabs onlyHepatitis Treatmententecavir BARACLUDE generic 1 SPglecaprevir/pibrentasvir MAVYRET brand 2 PA, SP

29




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

sofosbuvir/velpatasvir/voxilaprevir VOSEVI brand 2 PA, SP

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

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

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

30




abacavir/lamivudine/ zidovudine TRIZIVIR generic 1

didanosine VIDEX brand 2didanosine

delayed-release VIDEX EC generic 1

doravirine/lamivudine/ tenofovir disoproxil DELSTRIGO brand 2 QL

efavirenz/lamivudine/tenofovir disoproxil fumarate

SYMFISYMFI LO

brand 2 QL

emtricitabine EMTRIVA brand 2emtricitabine/rilpivirine/

tenofovir COMPLERA brand 2 PA

lamivudine EPIVIR generic 1lamivudine/tenofovir

disoproxil fumarate CIMDUO brand 2 QL

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

tenofovir ODEFSEY brand 2

emtricitabine/tenofovir alafenamide DESCOVY brand 2 QL

emtricitabine/tenofovir disoproxil TRUVADA brand 2

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

atazanavir REYATAZ POWDER PACKET brand 2


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

31




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

lamivudine TRIUMEQ brand 2 QL

atazanavir/cobicistat EVOTAZ brand 2 QLbictegravir/emtricitabine/

tenofovir alafenamide BIKTARVY brand 2 PA, QL

cobicistat TYBOST brand 2 QLcobicistat/elvitegravir/

emtricitabine/tenofovir STRIBILD brand 2 PA, QL

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

emtricitabine/tenofovir alafenamide fumarate

GENVOYA brand 2 PA, QL

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

extended-release MACROBID generic 1

nitrofurantoin macrocrystals MACRODANTIN generic 1

nitrofurantoin susp FURADANTIN SUSP 25 MG/5 ML generic 1

Members ≥ or equal to 8 years of age will require

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

32




Musculoskeletal

ArthritisDisease Modifying Anti-Rheumatic Drugsadalimumab HUMIRA brand 2 PA, SPapremilast OTEZLA brand 2 PA, SPazathioprine IMURAN generic 1baricitinib OLUMIANT brand 2 PA, QL, SPcanakinumab ILARIS brand 2 PA, SPcertolizumab pegol CIMZIA brand 2 PA, SPetanercept ENBREL brand 2 PA, SPhydroxychloroquine PLAQUENIL generic 1leflunomide ARAVA generic 1methotrexate generic 1

penicillamine DEPEN TITRATABLE brand 2 Diagnosis Required, QL, SP

sarilumab KEVZARA brand 2 PA, QL, SPsecukinumab COSENTYX brand 2 PA, SPsulfasalazine AZULFIDINE generic 1sulfasalazine delayed-

release AZULFIDINE EN-TABS generic 1

NSAIDs and Other Analgesicsacetaminophen TYLENOL generic 1 OTC

aspirinBAYERECOTRIN

generic 1 OTC

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

celecoxib CELEBREX generic 1 PA, QL

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

diclofenac potassium CATAFLAM generic 1diclofenac sodium

delayed-release VOLTAREN generic 1

diclofenac sodium extended-release VOLTAREN XR generic 1

etodolac LODINE generic 1 IR only

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

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

33




naproxen NAPROSYN generic 1

naproxen delayed release ENTERIC COATED-NAPROSYN generic 1

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

orphenadrine ER ORPHENADRINE CITRATE TAB SR generic 1 QL

Spasticitybaclofen BACLOFEN generic 1dantrolene DANTRIUM generic 1diazepam VALIUM generic 1 QLtizanidine ZANAFLEX generic 1 tabs only, QLMiscellaneousamifampridine RUZURGI brand 2 PA, QL, SP

OB-GYN

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

acetate DEPO-PROVERA generic 1 QL

Intravaginaletonogestrel/EE NUVARING brand 2 ring, QL

ortho diaphragmORTHO COILORTHO FLATORTHO FLEX

brand 2 QL

34




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

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

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

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

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

cap PROMETRIUM generic 1 Diagnosis Required, QL

Transdermal

norelgestromin/EEORTHO EVRAXULANE

generic 1

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

acetate/EE/iron ESTROSTEP FE generic 1 QL

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

35




Hormone Therapy/MenopauseEstrogens - Intravaginalestradiol ESTRACE CRM generic 1 QLyuvafem or estradiol

vaginal tablet VAGIFEM generic 1 QL

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

estradiol CLIMARAVIVELLE generic 1 QL

Estrogen/Progestinestrogens, conjugated/

medroxyprogesteronePREMPHASEPREMPRO brand 2

Progestinsmedroxyprogesterone

acetate PROVERA generic 1

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

bazedoxifene DUAVEE brand 2 QL

elagolix ORILISSA brand 2 PA, QLmethylergonovine METHERGINE generic 1tranexamic acid LYSTEDA generic 1 Diagnosis Required, QL

Ophthalmic

Allergyazelastine OPTIVAR generic 1 STcromolyn sodium CROLOM generic 1 QL

36




ketotifen ALAWAY OTC generic 1ketotifen ZADITOR generic 1 OTC, QL

naphazoline/glycerin CLEAR EYES REDNESS RELIEF generic 1

naphazoline HCL VASOCLEAR generic 1 soln 0.02%tetrahydrozoline/

zinc sulfate VISINE-AC generic 1

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

neomycin/hc CORTISPORIN generic 1 ointment

neomycin/polymyxin B/dexamethasone MAXITROL generic 1

neomycin/polymyxin B/hydrocortisone CORTISPORIN generic 1 suspension

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

dexamethasone TOBRADEX generic 1 QL

Nonsteroidalflurbiprofen OCUFEN generic 1

ketorolacACULARACULAR LS

generic 1

Steroidaldexamethasone sodium

phosphate DEXASOL generic 1

prednisolone acetate PRED FORTE generic 1 1%prednisolone phosphate INFLAMASE FORTE generic 1 1%GlaucomaBeta-Blockerscarteolol generic 1levobunolol BETAGAN generic 1 ophthalmic solutionmetipranolol OPTIPRANOLOL generic 1 0.3% ophthalmic solutiontimolol TIMOPTIC XE generic 1 gel forming solutiontimolol maleate TIMOPTIC generic 1Carbonic Anhydrase Inhibitorsdorzolamide TRUSOPT generic 1Carbonic Anhydrase Inhibitor/Beta-Blocker Combinationdorzolamide/

timolol maleate COSOPT generic 1

37




Mydriaticsatropine ISOPTO ATROPINE generic 1cyclopentolate CYCLOGYL generic 1 1%Oralacetazolamide ACETAZOLAMIDE generic 1acetazolamide

extended-release DIAMOX SEQUELS generic 1

methazolamide NEPTAZANE generic 1Topical - Parasympathomimeticspilocarpine ISOPTO CARPINE generic 1Topical - Sympathomimeticsbrimonidine ALPHAGAN P generic 1 0.15%brimonidine ALPHAGAN generic 1 0.2%epinephrine generic 1 opthImmunologic Agentslifitegrast XIIDRA brand 2 PAInfectionsBacterialbacitracin generic 1ciprofloxacin CILOXAN generic 1 solutionerythromycin ERYTHROMYCIN generic 1 QLgentamicin GENTAK generic 1neomycin/bacitracin/

polymyxin NEOSPORIN generic 1 ointment

neomycin/polymyxin B/gramicidin NEOSPORIN generic 1 solution

ofloxacin OCUFLOX generic 1polymyxin B/bacitracin POLYSPORIN generic 1polymyxin B/trimethoprim POLYTRIM generic 1sulfacetamide BLEPH-10 generic 1 oint/solntobramycin TOBREX generic 1Viral trifluridine VIROPTIC generic 1Prostaglandinslatanoprost XALATAN generic 1 QLMiscellaneous Ophthalmicsapraclonidin ophthalmic

solution LOPIDINE generic 1 QL

cysteamine 0.44% CYSTARAN brand 2 Diagnosis Required, QL, SP

sodium chloride hypertonic MURO 128 generic 1 soln 5%

38




Psychiatric

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

dextroamphetamine mixed salts

ADDERALL generic 1 Age Limits Apply, QL

amphetamine/ dextroamphetamine mixed salts extended-release

ADDERALL XR brand 2 Age Limits Apply, QL

atomoxetine STRATTERA generic 1 Age Limits Apply, QLguanfacine ER INTUNIV generic 1 Age Limits Apply, QLmethylphenidate RITALIN generic 1 tabs only, QLmethylphenidate

extended-releaseMETADATE CD METADATE ER

generic 1 Age Limits Apply, QL

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

20 mg, 30 mg, 40 mg

methylphenidate HCL ER 24hr generic 1

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

54 mg tablets, Mallinckrodt and Kremers

Urban labelers

39




Bipolar Disorderdivalproex sodium

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

authorization.divalproex sodium


lithium carbonate LITHIUM CARBONATE generic 1lithium carbonate

extended-releaseESKALITH CR LITHOBID

generic 1

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

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

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

extended-release WELLBUTRIN SR generic 1 QL

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

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

40




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

InsomniaBenzodiazepines

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

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

naloxone hcl SL tab SUBOXONE generic 1 QL, Diagnosis Required

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

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

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

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

41




clozapine CLOZARIL generic 125mg, 50mg, 100mg

only, Age Limit Applies, QL

olanzapine ZYPREXA generic 1 Age Limit Applies, tablets, QL

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

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

risperidone RISPERDAL CONSTA brand 2 Age Limit Applies, PA, QLrisperidone inj PERSERIS brand 2 PA, QL

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

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

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

phenylephrineDIMETAPP CLD ELX/

ALLERGY generic 1

brompheniramine/ pseudoephedrine

ACCUHIST DROPS UNI-HIST DROPS

generic 1

42




brompheniramine/ pseudoephedrine/ dextromethorphan

BROMFED DM generic 1 syrup

chlorphen tan/pyrilamine tan/PE tan

TRIOTANN PEDIATRIC SUSP

R-TANNAMINEgeneric 1 susp

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

chlorpheniramine/ dextromethorphan

ROBITUSSIN PED LIQ CGH/COLD

ROBITUSSIN LIQ CGH/CLD

DIMETAPP SYP CGH/CLDCORICIDIN TAB

CGH/CLD

generic 1

chlorpheniramine/ phenylephrine

RONDEC DROPSCARDEC DRO

generic 1 liquid

chlorpheniramine/ phenylephrine

RONDEC SYRUPCARDEC SYP

generic 1 syrup

chlorpheniramine/ pseudoephedrine LOHIST-D generic 1

chlorpheniramine tan/ phenylephrine tan RYNATAN PEDIATRIC SUSP generic 1 susp

codeine/guaifenesinGUIATUSS AC GG/CODEINE M-CLEAR WC

generic 1 QL

codeine/guaifenesin/ pseudoephedrine GUIATUSS DAC generic 1

codeine/promethazine PROMETHAZINE W/CODEINE generic 1 QL

codeine/promethazine/phenylephrine

PROMETHAZINE VC W/CODEINE generic 1 QL

dextromethorphan/ brompheniramine/pseudoephedrine

BROMETANE DXRESPERAL-DM

generic 1

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

43




dextromethorphan/ guaifenesin

GG/DM CRMUCINEX DMROBITUSSIN DMTUSSIN DM

generic 1 OTC

dextromethorphan- guaifenesin

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

dextromethorphan hbrROBITUSSIN SYP MAX-STROBITUSSIN PED SYP

generic 1 syrup

dextromethorphan polistirex extended-release

DELSYM brand 2 OTC

dextromethorphan/ promethazine

PHENERGAN DMPROMETHAZINE SYP DM

generic 1

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

guaifenesin ROBITUSSIN generic 1 OTCguaifenesin

extended-release MUCINEX generic 1 OTC

guaifenesin/ pseudoephedrine

ROBITUSSIN PE PSE/GG

generic 1 syrup, OTC

guaifenesin/ pseudoephedrine/ dextromethorphan

ROBITUSSIN CF generic 1

guaifenesin/ pseudoephedrine extended-release

MUCINEX D generic 1 OTC

hydrocodone/ homatropine

HYCODANHYDROMET SYPHYDROCODONE/

TAB HOMATROP

generic 1

phenylephrine/ brompheniramine/ dextromethorphan

generic 1 OTC

phenylephrine/ chlorpheniramine/ dextromethorphan

RONDEC DMSTATUSS DM SYPCARDEC DM SYPMINUTUSS DR SYP

generic 1 syrup

44




phenylephrine/ chlorpheniramine/ dextromethorphan

RONDEC DM DROPSCARDEC DM DROROBITUSSIN LIQ

CGH/ALRG

generic 1 liquid

phenylephrine/ chlorpheniramine/ dihydrocodeine

DIHYDRO-PE SYP generic 1

phenylephrine/ dextromethorphan

DIMETAPP DRO DCON/CGH generic 1

phenylephrine/ dextromethorphan/guaifenesin

ROBITUSSIN LIQ CGH/CLD generic 1

phenylephrine/ dextromethorphan/ guaifenesin

ROBITUSSIN LIQ CGH/CLD

phenylephrine/ephed/CPM w/ carbetapentane

RYNATUSS PEDIATRIC SUSP generic 1 susp

phenylephrine/ guaifenesin

ROBITUSSIN LIQ HD/CHST generic 1

phenylephrine/pyrilamine w/hydrocodone CODIMAL DH generic 1 syrup

pseudoephedrine/ acetaminophen/ dextromethorphan

MAPAP COLD TAB generic 1

pseudoephedrine/ chlorpheniramine/ dextromethorphan

PEDIACARE LIQ MULTI-SY

ROBITUSSIN LIQ PED NGHT

generic 1

pseudoephedrine/ dextromethorphan/guaifenesin

MULTI SYMPTOM TAB COLD RLF generic 1

pseudoephedrine/ iburprofen

CHILD IBUPRO SUS COLD

IBUOROFEN TAB COLD/SIN

generic 1

45




pseudoephedrine tan/ dexchlorphen tan/ DM tan

TANAFED DMX SUSPENSION

TRI-FED Xgeneric 1 susp

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

tripolidine/ pseudoephedrine

TRIPROL/PSE SYPAPHEDRID TAB

generic 1

Asthma/COPDInhalers - Beta Agonistsalbuterol sulfate VENTOLIN HFA generic 1 QLindacaterol ARCAPTA NEOHALER brand 2 QLolodaterol STRIVERDI RESPIMAT brand 2 QLInhalers - Corticosteroidsbeclomethasone QVAR REDIHALER brand 2 QL

mometasone ASMANEX HFA brand 2Patients 8 years and

older will require prior authorization

fluticasone furoate ARNUITY ELLIPTA brand 2 QLInhalers - Corticosteroid/Beta Agonist Combinationsfluticasone/salmeterol ADVAIR generic 1 PA, QLfluticasone/salmeterol AIRDUO RESPICLICK generic 1 QLfluticasone/salmeterol WIXELA INHUB brand 2 PA, QLInhalers - Othersipratropium/albuterol COMBIVENT RESPIMAT brand 2 inhaleripratropium HFA ATROVENT HFA brand 2omalizumab XOLAIR brand 2 PA, SPtiotropium/olodaterol STIOLTO RESPIMAT brand 2 QLumeclidinium inhalation INCRUSE ELLIPTA brand 2Inhalers for Nebulization

albuterol ACCUNEB generic 1

0.63 mg/3 ml and 1.25 mg /

3 ml, Covered for members less than 8

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

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

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

authorization. QLcromolyn INTAL generic 1 soln, QL

46




ipratropium ATROVENT generic 1 soln, QLipratropium/albuterol DUONEB generic 1 solnlevalbuterol HCl XOPENEX RESPULES generic 1 QL, STOral Agents - Leukotriene Modifiersmontelukast SINGULAIR generic 1 QLOral Agents - Theophyllinetheophylline THEOPHYLLINE generic 1 liquid

theophylline extended-release

THEOCHRONUNIPHYL

generic 1 tabs

Urological

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

methenamine hippurateHIPREXUREX

generic 1

oxybutynin chloride DITROPAN XL generic 1 QLoxybutynin IR DITROPAN generic 1

oxybutynin patch OXYTROL FOR WOMEN OTC PATCH brand 2

pentosan polysulfate sodium ELMIRON brand 2 Diagnosis Required, QL

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

47




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

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

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

minerals CALTRATE W/D generic 1 OTC, QL

cholecalciferol generic 1 drops 400 unit/0.03 ml, OTC

cholecalciferol generic 1 drops 2000 unit/0.03 ml, OTC

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

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



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

fluoride

GEL-KAMLURIDE LURIDE LOZI-TABSPREVIDENTPHOS-FLUR

generic 1

folic acid FOLIC ACID generic 1magnesium oxide MAG-OX generic 1 OTCmultiple vitamin chewable

tablet and drops AQUADEKS brand 2 Diagnosis Required, QL

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

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

prot succ-FA-CA & omega 3

COMPLETE NATALCARE PAK DHA brand 2

48




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

TRUST NATALCARE PAK DHA brand 2

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

PRUET DHA PAK SETONET PAK brand 2

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

PRUET DHAEC PAK brand 2

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

FOLTABS PAK PLUS DHA RE OB + DHA PAK brand 2

prenatal vit w/FE bisglycinate chelate-FA

VINATE II brand 2


GENTEX ADE 28-1 MG brand 2


VINATE AZ EX brand 2

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

prenatal vitamins w/folic acid

PRENATAL VITAMINS W/FOLIC ACID

MATERNANESTABS

generic 1 QL

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

FOLTABS PRENATALTRI RX

brand 2

vitamin A generic 1 OTCvitamin ADC/fluoride/

±iron drops TRI-VI-FLOR generic 1

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

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

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

zinc generic 1 OTC

49




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

potassium chloride extended-release

MICRO-K 10 K-DUR 10K-DUR 20K-TAB M20 KLOR-CON 8 KLOR-CON 10

generic 1 tabs

Miscellaneous

Anaphylaxis

epinephrineEPIPEN EPIPEN JR.

generic 1 QL

epinephrine SYMJEPI brand 2 QLAntidotesacetylcysteine 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

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

sodium chloride for nebulizer

HYPERSALNEBUSAL

generic 1

tezacaftor/ivcaftor SYMDEKO brand 2 PA, QL, SP

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

Hereditary Angioedemac1 esterase inhibitor, human BERINERT brand 2 PA, SPc1 esterase inhibitor, human HAEGARDA brand 2 PA, QL, SPicatibant FIRAZYR generic 1 PA, SPHyperphosphatemiacalcium acetate generic 1 667 mg tablet onlysevelamer RENVELA generic 1 ST, tablets

50




Medical Devicesinsulin pen needle QL, BD brand onlyinsulin syringes QL, BD brand onlylancets QLspacers QLMetabolic Modifierscarglumic acid CARBAGLU brand 2 PA, SPglycerol phenylbutyrate RAVICTI brand 2 PA, SP

sodium phenylbutyrate BUPHENYL ORAL POWDER generic 1 Diagnosis Required,

QL, SPVaccinediphtheria-tetanus tox

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

hepatitis a vaccine suspHAVRIXVAQTA

brand 2 QL

hepatitis b vaccine (recombinant)

ENGERIX-BRECOMBIVAX HB

brand 2 QL

hepatitis b vaccine recombinant adjuvanted

HEPLISAV-B brand 2 QL

human papillomavirus (hpv) 9-valent recomb vac

GARDASIL 9 brand 2 QL

human papillomavirus (hpv) quadrivalent recombinant vac

GARDASIL brand 2 QL

influenza virus vaccine live quadrivalent intranasal FLUMIST QUAD brand 2 QL

influenza virus vaccine recombinant hemagglutinin (ha) quadrivalent

FLUBLOK QUAD brand 2 QL

influenza virus vaccine split AFLURIA 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

51




influenza virus vaccine split quadrivalent

AFLURIA QUAD FLUARIX QUADFLULAVAL QUADFLUZONE QUAD

brand 2 QL

influenza virus vaccine split quadrivalent pf AFLURIA QUAD PF brand 2 QL

influenza virus vaccine tiss-cult subunit quadrivalent

FLUCELVAX QUAD brand 2 QL

influenza virus vaccine types a&b surface antigen

FLUAD brand 2 QL

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

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

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

MENACTRA brand 2 QL

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

MENVEO brand 2 QL

pneumococcal 13-valent conjugate PREVNAR 13 brand 2 QL

pneumococcal vaccine polyvalent

PNEUMOVAXPNEUMOVAX 23

brand 2 QL

tet tox-diph-acell pertuss ad

ADACELBOOSTRIX

brand 2 QL

tetanus-diphtheria toxoids (td)

TENIVACTET/DIP TOX INJ

brand 2 QL

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

varicella virus vac live for subcutaneous VARIVAX brand 2 QL

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

recombinant adjuvanted

SHINGRIX brand 2 Age Limits Apply, QL

52

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

Index of Covered Drugs

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

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

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

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

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

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

WAFER . . . . . . . . . . . . . . . . 26acidophilus/citrus pectin . . . . 26acidophilus/pectin . . . . . . . . . 26acitretin . . . . . . . . . . . . . . . . . . . 18ACLOVATE . . . . . . . . . . . . . . . . 17

ACTIGALL . . . . . . . . . . . . . . . . 26ACTIMMUNE . . . . . . . . . . . . . . . 6ACULAR . . . . . . . . . . . . . . . . . . 36ACULAR LS . . . . . . . . . . . . . . . 36acyclovir . . . . . . . . . . . . . . . . . . 29ADACEL . . . . . . . . . . . . . . . . . . 51ADALAT CC . . . . . . . . . . . . . . . . 9adalimumab . . . . . . . . . . . . . . . 32adapalene gel . . . . . . . . . . . . . 16ADDERALL . . . . . . . . . . . . . . . 38ADDERALL XR . . . . . . . . . . . . 38ADEMPAS . . . . . . . . . . . . . . . . 11ADLYXIN . . . . . . . . . . . . . . . . . 22ADMELOG SOLOSTAR . . . . . 22ADMELOG VIALS . . . . . . . . . . 22ADVAIR . . . . . . . . . . . . . . . . . . 45ADVIL . . . . . . . . . . . . . . . . .13, 32afatinib . . . . . . . . . . . . . . . . . . . . 4AFINITOR . . . . . . . . . . . . . . . . . . 4AFINITOR DISPERZ . . . . . . . . . 4AFLURIA . . . . . . . . . . . . . . . . . 50AFLURIA PF . . . . . . . . . . . . . . . 50AFLURIA QUAD . . . . . . . . . . . 51AFLURIA QUAD PF . . . . . . . . 51AFRIN . . . . . . . . . . . . . . . . . . . . 21AGRYLIN . . . . . . . . . . . . . . . . . . 7AIMOVIG . . . . . . . . . . . . . . . . . 14AIRDUO RESPICLICK . . . . . . 45AKINETON . . . . . . . . . . . . . . . . 15ALAVERT-D . . . . . . . . . . . . . . . 20ALAWAY OTC . . . . . . . . . . . . . 36albendazole . . . . . . . . . . . . . . . 26ALBENZA . . . . . . . . . . . . . . . . 26albuterol . . . . . . . . . . . . . . .45, 46albuterol sulfate . . . . . . . . . . . . 45alclometasone . . . . . . . . . . . . . 17ALDACTAZIDE . . . . . . . . . . . . 10ALDACTONE . . . . . . . . . . . . . . 10ALDARA . . . . . . . . . . . . . . . . . . 19ALDOMET . . . . . . . . . . . . . . . . 11

ALECENSA . . . . . . . . . . . . . . . . 4alectinib . . . . . . . . . . . . . . . . . . . 4alendronate . . . . . . . . . . . . . . . 23ALESSE . . . . . . . . . . . . . . . . . . 34alfuzosin ER . . . . . . . . . . . . . . . 46alginic acid/sodium

bicarbonate . . . . . . . . . . . . 25ALIGN . . . . . . . . . . . . . . . . . . . . 26ALINIA . . . . . . . . . . . . . . . . . . . 28alirocumab . . . . . . . . . . . . . . . . 11alitretinoin 1% gel . . . . . . . . . . . 6ALKERAN . . . . . . . . . . . . . . . . . 4allopurinol . . . . . . . . . . . . . . . . 33alogliptin . . . . . . . . . . . . . . . . . . 22alogliptin/metformin . . . . . . . . 22alogliptin/pioglitazone . . . . . . 22alpelisib . . . . . . . . . . . . . . . . . . . 4ALPHAGAN . . . . . . . . . . . . . . . 37ALPHAGAN P . . . . . . . . . . . . . 37alprazolam . . . . . . . . . . . . . . . . 38ALTACE . . . . . . . . . . . . . . . . . . . 8altretamine . . . . . . . . . . . . . . . . . 4alumina/magnesia . . . . . . . . . 25alumina/magnesia/

simethicone . . . . . . . . . . . . 25aluminum acetate . . . . . . .19, 20ALUNBRIG . . . . . . . . . . . . . . . . . 4amantadine . . . . . . . . . . . .15, 29AMARYL . . . . . . . . . . . . . . . . . 22AMBIEN . . . . . . . . . . . . . . . . . . 40ambrisentan . . . . . . . . . . . . . . . 11AMERGE . . . . . . . . . . . . . . . . . 14AMICAR . . . . . . . . . . . . . . . . . . 7amifampridine . . . . . . . . . . . . 33amiloride . . . . . . . . . . . . . . . . . 10amiloride/

hydrochlorothiazide . . . . . 10aminocaproic acid . . . . . . . . . . 7amiodarone tabs . . . . . . . . . . . . 8amitriptyline . . . . . . . . . . . .14, 39amitriptyline/perphenazine . . 39

53



AMLACTIN . . . . . . . . . . . . . . . . 19amlodipine . . . . . . . . . . . . . . . . . 9ammonium lactate . . . . . . . . . 19AMNESTEEM . . . . . . . . . . . . . 16amoxapine . . . . . . . . . . . . . . . . 39amoxicillin . . . . . . . . . . . . . . . . 27amoxicillin/clavulanate . . . . . . 27amphetamine/

dextroamphetamine mixed salts . . . . . . . . . . . . . . . . . . 38

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

ampicillin . . . . . . . . . . . . . . . . . 27anagrelide . . . . . . . . . . . . . . . . . 7anastrozole. . . . . . . . . . . . . . . . . 5ANTABUSE . . . . . . . . . . . . . . . 38ANTIVERT . . . . . . . . . . . . . . . . 24ANUSOL HC 2.5% . . . . . . . . . 19apalutamide . . . . . . . . . . . . . . . . 5APHEDRID TAB . . . . . . . . . . . 45apixaban . . . . . . . . . . . . . . . . . . 7apraclonidin ophthalmic

solution . . . . . . . . . . . . . . . 37apremilast . . . . . . . . . . . . . . . . 32aprepitant . . . . . . . . . . . . . . . . . 24APRESOLINE . . . . . . . . . . . . . 11APTIVUS . . . . . . . . . . . . . . . . . 31AQUADEKS . . . . . . . . . . . . . . 47ARALEN . . . . . . . . . . . . . . . . . . 31ARANESP . . . . . . . . . . . . . . . . . 7ARAVA . . . . . . . . . . . . . . . . . . . 32ARCAPTA NEOHALER . . . . . 45ARICEPT . . . . . . . . . . . . . . . . . 12ARIMIDEX . . . . . . . . . . . . . . . . . 5aripiprazole . . . . . . . . . . . . . . . 40aripiprazole ER injection . . . . 40aripiprazole injection . . . . . . . 40ARISTADA . . . . . . . . . . . . . . . . 40armodafinil . . . . . . . . . . . . . . . . 12ARNUITY ELLIPTA . . . . . . . . . 45

AROMASIN . . . . . . . . . . . . . . . . 5ARTANE . . . . . . . . . . . . . . . . . . 15asfotase alfa . . . . . . . . . . . . . . . 23ASMANEX HFA . . . . . . . . . . . . 45aspirin . . . . . . . . . . . 7, 12, 13, 32aspirin/acetaminophen/

caffeine . . . . . . . . . . . . . . . 12ASTELIN NASAL SPRAY

0.1% . . . . . . . . . . . . . . . . . 20ATARAX . . . . . . . . . . . . . . . . . . 20atazanavir . . . . . . . . . . . . . . . . . 30atazanavir/cobicistat . . . . . . . 31atenolol . . . . . . . . . . . . . . . . . . . . 9atenolol/chlorthalidone . . . . . . 9ATIVAN . . . . . . . . . . . . . . . . . . . 38atomoxetine . . . . . . . . . . . . . . 38atorvastatin . . . . . . . . . . . . . . . 11atovaquone . . . . . . . . . . . . . . . 28atropine . . . . . . . . . . . . . . .24, 37ATROVENT . . . . . . . . 21, 45, 46ATROVENT HFA . . . . . . . . . . . 45ATROVENT NASAL SPRAY . 21AUBAGIO . . . . . . . . . . . . . . . . . 14AUGMENTIN . . . . . . . . . . . . . . 27AVITA . . . . . . . . . . . . . . . . . . . . 17axitinib . . . . . . . . . . . . . . . . . . . . 4AYGESTIN . . . . . . . . . . . . ., 2035azathioprine . . . . . . . . . . . . . 6, 32azelastine . . . . . . . . . . . . . . . . . 35azelaic acid . . . . . . . . . . . . . . . 16azithromycin . . . . . . . . . . . . . . 27aztreonam . . . . . . . . . . . . . . . . 49AZULFIDINE . . . . . . . . . . .26, 32AZULFIDINE EN-TABS . . .26, 32

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

bacitracin/polymyxin/ neomycin/hc . . . . . . . . . . . 36

baclofen . . . . . . . . . . . . . . . . . . 33BACTRIM . . . . . . . . . . . . . . . . . 28BACTRIM DS . . . . . . . . . . . . . . 28BACTROBAN . . . . . . . . . . . . . 17BALVERSA . . . . . . . . . . . . . . . . 4BALZIVA . . . . . . . . . . . . . . . . . . 34BANZEL . . . . . . . . . . . . . . . . . . 16BARACLUDE . . . . . . . . . . . . . . 28baricitinib . . . . . . . . . . . . . . . . 32BASAGLAR . . . . . . . . . . . . . . . 22BAYER . . . . . . . . . . . . . . . . . 7, 32becaplermin gel . . . . . . . . . . . 19beclomethasone . . . . . . . . . . . 45bedaquiline . . . . . . . . . . . . . . . 31BENADRYL . . . . . . . . . . . .20, 21benazepril . . . . . . . . . . . . . . . . . 8benazepril/

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

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

augmented . . . . . . . . . . . . 18betamethasone dipropionate 18betamethasone val . . . . . . . . . 17BETAPACE . . . . . . . . . . . . . . . . 9BETAPACE AF . . . . . . . . . . . . . . 9betaxolol . . . . . . . . . . . . . . . . . . . 9bethanechol . . . . . . . . . . . . . . . 46

54


Index of Covered DrugsBETHKIS . . . . . . . . . . . . . . . . . 49betrixaban . . . . . . . . . . . . . . . . . 7BEVYXXA . . . . . . . . . . . . . . . . . 7bexarotene caps and topical

gel . . . . . . . . . . . . . . . . . . . . . 6BIAXIN . . . . . . . . . . . . . . . . . . . 27BIAXIN XL . . . . . . . . . . . . . . . . 27bicalutamide . . . . . . . . . . . . . . . 5BICITRA . . . . . . . . . . . . . . . . . . 46bictegravir/emtricitabine/

tenofovir alafenamide . . . 31BIKTARVY . . . . . . . . . . . . . . . . 31BILTRICIDE . . . . . . . . . . . . . . . 26BIOGAIA . . . . . . . . . . . . . . . . . . 26biperiden . . . . . . . . . . . . . . . . . 15bisoprolol . . . . . . . . . . . . . . . . . . 9bisoprolol/

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

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

pseudoephedrine . . . .41, 42brompheniramine/

pseudoephedrine/dextromethorphan . . . . . . 42

budesonide . . . . . . . . . . . .25, 45bumetanide . . . . . . . . . . . . . . . 10BUMEX . . . . . . . . . . . . . . . . . . . 10BUPHENYL ORAL

POWDER . . . . . . . . . . . . . . 50buprenorphine . . . . . . . . . . . . 40buprenorphine hcl/naloxone

hcl SL tab . . . . . . . . . . . . . 40

buprenorphine/naloxone . . . . 40buprenorphine patch . . . . . . 13bupropion . . . . . . . . . . . . . . . . 39bupropion extended-release . 39BUSPAR . . . . . . . . . . . . . . . . . . 38buspirone . . . . . . . . . . . . . . . . . 38busulfan . . . . . . . . . . . . . . . . . . . 4butalbital/acetaminophen/

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

Cc1 esterase inhibitor, human . 49cabergoline . . . . . . . . . . . . . . . 23CABLIVI . . . . . . . . . . . . . . . . . . . 7CABOMETYX . . . . . . . . . . . . . . 4cabozantinib . . . . . . . . . . . . . . . 4CAFERGOT . . . . . . . . . . . . . . . 14calamine . . . . . . . . . . . . . . . . . . 19CALAN . . . . . . . . . . . . . . . .10, 14CALAN SR . . . . . . . . . . . . . . . . 10calcipotriene . . . . . . . . . . . . . . 18calcitonin-salmon . . . . . . . . . . 23calcitriol . . . . . . . . . . . . . . .18, 47calcitriol oral soln . . . . . . . . . . 47calcium . . . . . . . . 2, 9, 24, 47, 49calcium acetate . . . . . . . . . . . . 49calcium carb-vit D

w/ minerals . . . . . . . . . . . . 47CALQUENCE . . . . . . . . . . . . . . 4CALTRATE W/D . . . . . . . . . . . 47CAMPRAL . . . . . . . . . . . . . . . . 38canakinumab . . . . . . . . . . . . . 32CANASA . . . . . . . . . . . . . . . . . 26capecitabine . . . . . . . . . . . . . . . 4CAPITROL . . . . . . . . . . . . . . . . 19caplacizumab-yhdp . . . . . . . . . 7

CAPOTEN . . . . . . . . . . . . . . . . . 8CAPOZIDE . . . . . . . . . . . . . . . . . 8CAPRELSA . . . . . . . . . . . . . . . . 5capsaicin . . . . . . . . . . . . . . . . . 32captopril . . . . . . . . . . . . . . . . . . . 8captopril/hydrochlorothiazide . 8CARAFATE . . . . . . . . . . . . . . . . 25CARAFATE SUSPENSION . . 25CARBAGLU . . . . . . . . . . . . . . . 50carbamazepine . . . . . . . . . . . . 15carbamazepine extended-

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

extended-release . . . . . . . 15CARDEC DM DRO . . . . . . . . . 44CARDEC DM SYP . . . . . . . . . 43CARDEC DRO . . . . . . . . . . . . . 42CARDEC SYP . . . . . . . . . . . . . 42CARDIZEM . . . . . . . . . . . . . . . 10CARDIZEM CD . . . . . . . . . . . . 10CARDIZEM SR . . . . . . . . . . . . 10CARDURA . . . . . . . . . . . . . . 8, 46carglumic acid . . . . . . . . . . . . . 50carteolol . . . . . . . . . . . . . . . . . . 36carvedilol . . . . . . . . . . . . . . . . . . 9casanthranol-docusate

sodium . . . . . . . . . . . . . . . . 24CASODEX . . . . . . . . . . . . . . . . . 5CATAFLAM . . . . . . . . . . . .12, 32CATAPRES . . . . . . . . . . . . . . . . . 8CAYSTON . . . . . . . . . . . . . . . . 49CECLOR . . . . . . . . . . . . . . . . . 27cefaclor . . . . . . . . . . . . . . . . . . . 27cefadroxil . . . . . . . . . . . . . . . . . 27cefdinir . . . . . . . . . . . . . . . . . . . 27cefprozil . . . . . . . . . . . . . . . . . . 27CEFTIN . . . . . . . . . . . . . . . . . . . 27cefuroxime axetil . . . . . . . . . . . 27

55



CEFZIL . . . . . . . . . . . . . . . . . . . 27CELEBREX . . . . . . . . . . . . . . . 32celecoxib . . . . . . . . . . . . . . . . . 32CELEXA . . . . . . . . . . . . . . . . . . 39CELLCEPT . . . . . . . . . . . . . . . . . 6CENTRUM . . . . . . . . . . . . . . . . 47cephalexin . . . . . . . . . . . . . . . . 27ceritinib . . . . . . . . . . . . . . . . . . . . 4certolizumab pegol . . . . . . . . . 32cetirizine . . . . . . . . . . . . . . . . . . 20cetirizine chew tab . . . . . . . . . 20CETYLEV . . . . . . . . . . . . . . . . 49CHANTIX . . . . . . . . . . . . . . . . . 41CHEMET . . . . . . . . . . . . . . . . . 49CHILD IBUPRO SUS COLD . 44CHLOR-TRIMETON

ALLERGY . . . . . . . . . . . . . 20CHLOR-TRIMETON SYRUP . 20chloral hydrate . . . . . . . . . . . . . 40chlorambucil . . . . . . . . . . . . . . . 4chlordiazepoxide. . . . . . . . . . . 38chlorhexidine gluconate. . . . . 21chloroquine phosphate . . . . . 31chlorothiazide . . . . . . . . . . . . . 10chloroxine . . . . . . . . . . . . . . . . 19chlorphen tan/carbetapentane

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

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

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

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

dextromethorphan . . . 42-44chlorpheniramine/

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

pseudoephedrine . . . . . . . 42chlorpromazine . . . . . . . . . . . . 41

chlorthalidone . . . . . . . . . . . 9, 10chlorzoxazone . . . . . . . . . . . . . 33CHOLBAM . . . . . . . . . . . . . . . . 23cholecalciferol . . . . . . . . . . . . . 47cholestyramine . . . . . . . . . . . . 10cholic acid . . . . . . . . . . . . . . . . 23choriogonadotropin alfa . . . . . 35chorionic gonadotropin . . . . . 35ciclopirox . . . . . . . . . . . . . . . . . 18cilostazol . . . . . . . . . . . . . . . . . . 7CILOXAN . . . . . . . . . . . . . . . . . 37CIMDUO . . . . . . . . . . . . . . . . . . 30cimetidine . . . . . . . . . . . . . . . . 25CIMZIA . . . . . . . . . . . . . . . . . . . 32cinacalcet . . . . . . . . . . . . . . . . . 23CIPRO . . . . . . . . . . . . . . . . . . . 27ciprofloxacin . . . . . . . . . . .27, 37citalopram . . . . . . . . . . . . . . . . 39CLARAVIS . . . . . . . . . . . . . . . . 16clarithromycin . . . . . . . . . . . . . 27clarithromycin ER . . . . . . . . . . 27CLEAR EYES REDNESS

RELIEF . . . . . . . . . . . . . . . . 36clemastine . . . . . . . . . . . . . . . . 20CLEOCIN . . . . . . . . . . 16, 31, 35CLEOCIN T . . . . . . . . . . . . . . . 16CLIMARA . . . . . . . . . . . . . . . . . 35clindamycin . . . . . . . . 16, 31, 35CLINORIL . . . . . . . . . . . . . .13, 33clobazam . . . . . . . . . . . . . . . . . 15clobetasol propionate. . . . . . . 18clobetasol propionate emollient

base cream . . . . . . . . . . . 18clonazepam . . . . . . . . . . . .15, 38clonidine. . . . . . . . . . . . . . . . . . . 8clopidogrel . . . . . . . . . . . . . . . . . 7clorazepate . . . . . . . . . . . . . . . 38clotrimazole . . . . . . . . . . . .18, 28clotrimazole with

betamethasone . . . . . . . . . 18clozapine . . . . . . . . . . . . . . . . . 41

CLOZARIL . . . . . . . . . . . . . . . . 41cobicistat . . . . . . . . . . . . . . . . . 31cobicistat/elvitegravir/

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

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

phenylephrine . . . . . . . . . . 42CODIMAL DH . . . . . . . . . . . . . 44COGENTIN . . . . . . . . . . . . . . . 15COLACE . . . . . . . . . . . . . . . . . 24colchicine . . . . . . . . . . . . . . . . 33COLYTE . . . . . . . . . . . . . . . . . . 24COMBIVENT RESPIMAT . . . . 45COMBIVIR . . . . . . . . . . . . . . . . 30COMETRIQ . . . . . . . . . . . . . . . . 4COMMITT OTC . . . . . . . . . . . . 41COMPAZINE . . . . . . . . . . . . . . 24COMPLERA . . . . . . . . . . . . . . 30COMPLETE NATALCARE PAK

DHA . . . . . . . . . . . . . . . . . . 47COMPOUND W . . . . . . . . . . . 18COMTAN . . . . . . . . . . . . . . . . . 15CONDYLOX SOL . . . . . . . . . . 19conjugated estrogen/

bazedoxifene . . . . . . . . . . 35COPAXONE . . . . . . . . . . . . . . . 14CORDARONE . . . . . . . . . . . . . . 8COREG . . . . . . . . . . . . . . . . . . . 9CORICIDIN TAB CGH/CLD . . 42CORTEF . . . . . . . . . . . . . . . . . . 21cortisone acetate . . . . . . . . . . 21CORTISPORIN . . . . . . . . .20, 36CORTISPORIN OTIC . . . . . . . 20CORTIZONE . . . . . . . . . . . . . . 17

56


Index of Covered DrugsCORTIZONE-10 INTENSIVE

HEALING . . . . . . . . . . . . . . 17COSENTYX . . . . . . . . . . . . . . . 32COSOPT . . . . . . . . . . . . . . . . . 36COTELLIC . . . . . . . . . . . . . . . . . 4COUMADIN . . . . . . . . . . . . . . . . 7COZAAR . . . . . . . . . . . . . . . . . . 8CREON . . . . . . . . . . . . . . . . . . . 26CREON 3000 UNIT . . . . . . . . 26CRIXIVAN . . . . . . . . . . . . . . . . . 30crizotinib . . . . . . . . . . . . . . . . . . . 4crofelemer . . . . . . . . . . . . . . . . 24CROLOM . . . . . . . . . . . . . . . . . 35cromolyn . . . . . . . . . . 21, 35, 45cromolyn sodium . . . . . . .21, 35crotamiton . . . . . . . . . . . . . . . . 19CULTURELLE . . . . . . . . . . . . . 26CUTIVATE . . . . . . . . . . . . . . . . 17cyanocobalamin . . . . . . . . . . . 47CYCLESSA . . . . . . . . . . . . . . . 34cyclobenzaprine . . . . . . . . . . . 33CYCLOGYL . . . . . . . . . . . . . . . 37cyclopentolate . . . . . . . . . . . . . 37cyclophosphamide . . . . . . . . . . 4cycloserine . . . . . . . . . . . . . . . . 28cyclosporine . . . . . . . . . . . . . . . 6cyclosporine, modified . . . . . . . 6CYMBALTA . . . . . . . . . . . . . . . 39cyproheptadine . . . . . . . . . . . . 20CYSTAGON . . . . . . . . . . . . . . . . 6CYSTARAN . . . . . . . . . . . . . . . 37cysteamine 0.44% . . . . . . . . . 37cysteamine bitartrate . . . . . . . . 6CYTOMEL . . . . . . . . . . . . . . . . 23CYTOTEC . . . . . . . . . . . . . . . . 26CYTOVENE . . . . . . . . . . . . . . . 28CYTOXAN . . . . . . . . . . . . . . . . . 4

DD3-50 CAP . . . . . . . . . . . . . . . . 47

D.H.E. 45 . . . . . . . . . . . . . . . . . 14dabrafenib . . . . . . . . . . . . . . . . . 4danazol . . . . . . . . . . . . . . . . . . . 34DANOCRINE . . . . . . . . . . . . . . 34DANTRIUM . . . . . . . . . . . . . . . 33dantrolene . . . . . . . . . . . . . . . . 33dapsone . . . . . . . . . . . . . . . . . . 31DARAPRIM . . . . . . . . . . . . . . . 31darbepoetin alfa . . . . . . . . . . . . 7darunavir . . . . . . . . . . . . . .30, 31darunavir/cobicistat . . . . . . . . 31dasatinib . . . . . . . . . . . . . . . . . . . 4DAURISMO . . . . . . . . . . . . . . . . 6DAYPRO . . . . . . . . . . . . . . .13, 33DDAVP . . . . . . . . . . . . . . . . . . . 23DEBROX . . . . . . . . . . . . . . . . . 20DECADRON . . . . . . . . . . . . . . 21deferasirox . . . . . . . . . . . . . . . . . 7DELATESTRYL . . . . . . . . . . . . 21delavirdine . . . . . . . . . . . . . . . . 29DELSTRIGO . . . . . . . . . . . . . . 30DELSYM . . . . . . . . . . . . . . . . . . 43DELTASONE . . . . . . . . . . . . . . 21DELZICOL . . . . . . . . . . . . . . . 25DEMADEX . . . . . . . . . . . . . . . . 10DEPAKENE . . . . . . . . . . . . . . . 16DEPAKOTE . . . . . . . . 14, 15, 39DEPAKOTE SPRINKLE . .14, 15DEPEN TITRATABLE . . . . . . . 32DEPO-PROVERA . . . . . . . . . . 33DEPO-TESTOSTERONE . . . . 21DERMA-SMOOTHE OIL/FS . 17DERMAPHOR OINTMENT . . 19DERMATOP . . . . . . . . . . . . . . . 17DESCOVY . . . . . . . . . . . . . . . . 30DESENEX . . . . . . . . . . . . . . . . 18desipramine . . . . . . . . . . . . . . . 39desmopressin . . . . . . . . . . . . . 23desogestrel/EE . . . . . . . . .33, 34DESYREL . . . . . . . . . . . . . . . . . 40

DETROL . . . . . . . . . . . . . . . . . . 46dexamethasone . . . . . . . .21, 36dexamethasone sodium

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

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

guaifenesin 42, 43dextromethorphan/

brompheniramine/pseudoephedrine . . . . . . . 42

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

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

DIAMOX SEQUELS . . . . . . . . 37DIASTAT ACUDIAL . . . . . . . . 15diazepam . . . . . . . . . . 15, 33, 38diclofenac 1% gel . . . . . . . . . . 32diclofenac potassium . . . .12, 32diclofenac sodium delayed-

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

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

57



diltiazem . . . . . . . . . . . . . . . . . . 10diltiazem extended-release . . 10diltiazem sustained-release . . 10DIMEATAPP DRO

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

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

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

adsorbed (dt) im . . . . . . . . 50DIPROLENE . . . . . . . . . . .17, 18DIPROLENE AF . . . . . . . . . . . 17dipyridamole . . . . . . . . . . . . . . . 7DISALCID . . . . . . . . . . . . . . . . . 33disopyramide . . . . . . . . . . . . . . . 8disopyramide

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

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

release . . . . . . . . . 14, 15, 39docosanol . . . . . . . . . . . . . . . . 29docusate calcium plus . . . . . . 24docusate potasssium . . . . . . . 24docusate sodium . . . . . . . . . . 24dofetilide. . . . . . . . . . . . . . . . . . . 9dolutegravir . . . . . . . . . . . .29, 31dolutegravir/lamivudine . . . . 31dolutegravir/rilpivirine . . . . . . . 31DOMEBORO OTIC . . . . . . . . . 20donepezil . . . . . . . . . . . . . . . . . 12

doravirine/lamivudine/ tenofovir disoproxil . . . . . . . . . . . . . 30

dornase alfa . . . . . . . . . . . . . . . 49dorzolamide . . . . . . . . . . . . . . . 36dorzolamide/timolol maleate 36DOSTINEX . . . . . . . . . . . . . . . . 23DOVATO . . . . . . . . . . . . . . . . . 31DOVONEX . . . . . . . . . . . . . . . . 18doxazosin . . . . . . . . . . . . . . . 8, 46doxepin . . . . . . . . . . . . . . . . . . 39doxycycline monohydrate . . . 28doxylamine succinate . . . . . . . 40DRISDOL . . . . . . . . . . . . . . . . . 47DROXIA . . . . . . . . . . . . . . . . . . . 6DUAVEE . . . . . . . . . . . . . . . . . 35dulaglutide . . . . . . . . . . . . . . . 22duloxetine . . . . . . . . . . . . . . . . 39DUOFILM . . . . . . . . . . . . . . . . . 18DUONEB . . . . . . . . . . . . . . . . . 46DURAGESIC . . . . . . . . . . . . . . 13DURATUSS DM ELX . . . . . . . 42DURICEF . . . . . . . . . . . . . . . . . 27DYAZIDE . . . . . . . . . . . . . . . . . 10

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

disoproxil fumarate . . . . . . 30EFFEXOR . . . . . . . . . . . . . . . . . 39EFFEXOR XR . . . . . . . . . . . . . . 39EFFIENT . . . . . . . . . . . . . . . . . . 7EFUDEX . . . . . . . . . . . . . . . . . . 19elagolix . . . . . . . . . . . . . . . . . . 35ELAVIL . . . . . . . . . . . . . . . .14, 39ELDEPRYL . . . . . . . . . . . . . . . . 15

electrolyte . . . . . . . . . . . . . . . . . 47ELIDEL . . . . . . . . . . . . . . . . . . 19ELIMITE . . . . . . . . . . . . . . . . . . 19ELIQUIS . . . . . . . . . . . . . . . . . . . 7ELMIRON . . . . . . . . . . . . . . . . . 46ELOCON . . . . . . . . . . . . . . . . . 17eltrombopag . . . . . . . . . . . . . . . 7elvitegravir/cobicistat/

emtricitabine/tenofovir alafenamide fumarate . . . 31

EMEND . . . . . . . . . . . . . . . . . . 24EMGALITY . . . . . . . . . . . . . . . 14emicizumab-kxwh . . . . . . . . . . . 7EMLA . . . . . . . . . . . . . . . . . . . . 19emollients . . . . . . . . . . . . . . . . . 19emtricitabine . . . . . . . . . . .30, 31emtricitabine/rilpivirine/

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

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

disoproxil . . . . . . . . . . . . . . 30EMTRIVA . . . . . . . . . . . . . . . . . 30enalapril . . . . . . . . . . . . . . . . . . . 8enalapril/hydrochlorothiazide . 8enasidenib . . . . . . . . . . . . . . . . 4ENBREL . . . . . . . . . . . . . . . . . . 32enfuvirtide . . . . . . . . . . . . . . . . 31ENGERIX-B . . . . . . . . . . . . . . . 50enoxaparin . . . . . . . . . . . . . . . . . 7entacapone . . . . . . . . . . . . . . . 15entecavir . . . . . . . . . . . . . . . . . . 28ENTERIC COATED-

NAPROSYN . . . . . . . . .13, 33ENTOCORT EC . . . . . . . . . . . . 25ENTRESTO . . . . . . . . . . . . . . . . 8ENULOSE . . . . . . . . . . . . . . . . 24epinephrine . . . . . . . . . . . .37, 49EPIPEN . . . . . . . . . . . . . . . . . . . 49EPIPEN JR. . . . . . . . . . . . . . . . 49EPIVIR . . . . . . . . . . . . . . . .29, 30

58


Index of Covered DrugsEPIVIR HBV . . . . . . . . . . . . . . . 29epoetin alfa-epbx . . . . . . . . . . . 7EPZICOM . . . . . . . . . . . . . . . . . 29erdafitinib . . . . . . . . . . . . . . . . . 4erenumab-aooe . . . . . . . . . . . . 14ergocalciferol (D2) . . . . . . . . . 47ergotamine/caffeine . . . . . . . . 14ERIVEDGE . . . . . . . . . . . . . . . . . 7ERLEADA . . . . . . . . . . . . . . . . . 5erlotinib . . . . . . . . . . . . . . . . . . . 4ertugliflozin . . . . . . . . . . . . . . . 22ertugliflozin/metformin . . . . . . 22ERYC . . . . . . . . . . . . . . . . . . . . 27ERYGEL . . . . . . . . . . . . . . . . . . 16ERYPED . . . . . . . . . . . . . . . . . 27ERYTHROCIN . . . . . . . . . . . . . 27erythromycin . . . . . . . 16, 27, 37erythromycin delayed-release 27erythromycin ethylsuccinate . 27erythromycin stearate . . . . . . . 27erythromycin/sulfisoxazole . . 27escitalopram . . . . . . . . . . . . . . 39ESGIC . . . . . . . . . . . . . . . . . . . 12ESKALITH CR . . . . . . . . . . . . . 39esomeprazole . . . . . . . . . . . . . 25esomeprazole granules . . . . 25ESTRACE . . . . . . . . . . . . . . . . . 35ESTRACE CRM. . . . . . . . . . . . 35estradiol . . . . . . . . . . . . . . . . . . 35estrogens, conjugated . . . . . . 35estrogens, conjugated/

medroxyprogesterone . . . 35estropipate . . . . . . . . . . . . . . . . 35ESTROSTEP FE . . . . . . . . . . . 34etanercept . . . . . . . . . . . . . . . . 32ethambutol . . . . . . . . . . . . . . . . 27ethosuximide . . . . . . . . . . . . . . 15ethynodiol diacetate/EE . . . . . 34etidronate . . . . . . . . . . . . . . . . . 23etodolac . . . . . . . . . . . . . . .12, 32

etonogestrel/EE . . . . . . . . . . . 33etoposide . . . . . . . . . . . . . . . . . . 6etravirine . . . . . . . . . . . . . . . . . . 29EULEXIN . . . . . . . . . . . . . . . . . . 5EURAX . . . . . . . . . . . . . . . . . . . 19everolimus . . . . . . . . . . . . . . . . . 4evolocumab . . . . . . . . . . . . . . 11EVOTAZ . . . . . . . . . . . . . . . . . 31EVISTA . . . . . . . . . . . . . . . . . . . 23EXCEDRIN MIGRAINE . . . . . . 12EXELON PATCH . . . . . . . . . . . 12EXELON TABS . . . . . . . . . . . . 12exemestane . . . . . . . . . . . . . . . . 5EXJADE . . . . . . . . . . . . . . . . . . . 7ezetimibe . . . . . . . . . . . . . . . . . 11

Ffamotidine . . . . . . . . . . . . . . . . 25FARESTON . . . . . . . . . . . . . . . . 5FARYDAK . . . . . . . . . . . . . . . . . . 4febuxostat . . . . . . . . . . . . . . . . 33felbamate . . . . . . . . . . . . . . . . . 15felbamate oral susp . . . . . . . . 15FELBATOL . . . . . . . . . . . . . . . . 15FELDENE . . . . . . . . . . . . . .13, 33felodipine extended-release . . 9FEMARA . . . . . . . . . . . . . . . . . . 5fenofibrate . . . . . . . . . . . . . . . . 10fentanyl transdermal . . . . . . . . 13FEOSOL . . . . . . . . . . . . . . . . . . 47ferrous sulfate . . . . . . . . . . . . . 47fidaxomicin . . . . . . . . . . . . . . . 27filgrastim . . . . . . . . . . . . . . . . . . . 7FINACEA . . . . . . . . . . . . . . . . . 16finasteride . . . . . . . . . . . . . . . . 46fingolimod . . . . . . . . . . . . . . . . 14FIORICET . . . . . . . . . . . . . .12, 13FIORICET W/CODEINE . . . . . 13FIORINAL . . . . . . . . . . . . . .12, 13FIORINAL W/CODEINE . . . . . 13

FIRAZYR . . . . . . . . . . . . . . . . . 49FIRVANQ . . . . . . . . . . . . . . . . . 28FLAGYL . . . . . . . . . . . . . . .31, 35flecainide . . . . . . . . . . . . . . . . . . 9FLEXERIL . . . . . . . . . . . . . . . . . 33FLOMAX. . . . . . . . . . . . . . . . . . 46FLONASE . . . . . . . . . . . . . . . . . 20FLORAJEN . . . . . . . . . . . . . . . 26FLORANEX . . . . . . . . . . . . . . . 26FLORASTOR . . . . . . . . . . . . . . 26FLORINEF . . . . . . . . . . . . . . . . 21FLOXIN . . . . . . . . . . . . . . . .20, 27FLOXIN OTIC . . . . . . . . . . . . . . 20FLUAD . . . . . . . . . . . . . . . . . . . 51FLUARIX QUAD . . . . . . . . . . . 51FLUBLOK QUAD . . . . . . . . . . . 50FLUCELVAX QUAD . . . . . . . . 51fluconazole . . . . . . . . . . . .28, 35fludrocortisone . . . . . . . . . . . . 21FLULAVAL QUAD . . . . . . . . . . 51FLUMADINE . . . . . . . . . . . . . . 29FLUMIST QUAD . . . . . . . . . . . 50fluocinolone acetonide . . . . . . 17fluocinonide . . . . . . . . . . . . . . . 18fluocinonide emulsified base 18fluoride . . . . . . . . . . . . . . . .47, 48fluorouracil . . . . . . . . . . . . . . . . 19fluoxetine . . . . . . . . . . . . . . . . . 39fluphenazine . . . . . . . . . . . . . . 41fluphenazine decanoate . . . . 41flurbiprofen . . . . . . . . . . . . . . . 36flutamide . . . . . . . . . . . . . . . . . . 5fluticasone . . . . . . . . . 17, 20, 45fluticasone furoate . . . . . . . . . 45fluticasone propionate . . . . . . 17fluticasone/salmeterol . . . . . . 45fluvoxamine . . . . . . . . . . . . . . . 38FLUZONE HD PF . . . . . . . . . . 50FLUZONE QUAD. . . . . . . . . . . 51folic acid . . . . . . . . . . . . . . .47, 48

59



FOLTABS PAK PLUS DHA RE OB + DHA PAK . . . . . . . . . 48

FOLTABS PRENATAL . . . . . . . 48FORTAMET . . . . . . . . . . . . . . . 23FORTICAL . . . . . . . . . . . . . . . . 23FOSAMAX . . . . . . . . . . . . . . . . 23fosamprenavir . . . . . . . . . . . . . 30fosinopril. . . . . . . . . . . . . . . . . . . 8fosinopril/hydrochlorothiazide 8FURADANTIN SUSP

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

Ggabapentin . . . . . . . . . . . . . . . . 15GABITRIL . . . . . . . . . . . . . . . . . 16galantamine . . . . . . . . . . . . . . . 12galcanezumab-gnim . . . . . . . 14ganciclovir . . . . . . . . . . . . . . . . 28GARDASIL . . . . . . . . . . . . . . . . 50GARDASIL 9 . . . . . . . . . . . . . . 50GATTEX . . . . . . . . . . . . . . . . . . 26gefitinib . . . . . . . . . . . . . . . . . . . . 4GEL-KAM . . . . . . . . . . . . . . . . . 47gemfibrozil . . . . . . . . . . . . . . . . 10GENTAK . . . . . . . . . . . . . . .17, 37gentamicin . . . . . . . . . . . . .17, 37GENTEX ADE 28-1 MG . . . . . 48GENVOYA . . . . . . . . . . . . . . . . 31GEODON . . . . . . . . . . . . . . . . . 41GG/CODEINE . . . . . . . . . . . . . 42GG/DM CR . . . . . . . . . . . . . . . 43GILENYA . . . . . . . . . . . . . . . . . 14GILOTRIF . . . . . . . . . . . . . . . . . . 4glasdegib . . . . . . . . . . . . . . . . . 6glatiramer acetate . . . . . . . . . . 14glecaprevir/pibrentasvir . . . . 28GLEEVEC . . . . . . . . . . . . . . . . . 5GLEOSTINE . . . . . . . . . . . . . . . . 4glimepiride . . . . . . . . . . . . . . . . 22

glipizide . . . . . . . . . . . . . . . . . . 23glipizide extended-release . . . 23GLUCAGON . . . . . . . . . . . . . . 21glucagon, human

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

pseudoephedrine . . . .42, 43guaifenesin/pseudoephedrine

extended-release . . . . . . . 43guaifenesin/pseudoephedrine/

dextromethorphan . . . . . . 43guanabenz . . . . . . . . . . . . . . . . 11guanfacine . . . . . . . . . . . . . . 8, 38guanfacine ER . . . . . . . . . . . . . 38GUIATUSS AC . . . . . . . . . . . . . 42GUIATUSS DAC . . . . . . . . . . . 42

HHAEGARDA . . . . . . . . . . . . . . . 49HALCION . . . . . . . . . . . . . . . . . 40HALDOL . . . . . . . . . . . . . . . . . . 41HALDOL DECANOATE . . . . . 41

halobetasol . . . . . . . . . . . . . . . 18haloperidol . . . . . . . . . . . . . . . . 41haloperidol decanoate . . . . . . 41HAVRIX . . . . . . . . . . . . . . . . . . . 50HECORIA . . . . . . . . . . . . . . . . . . 6HEMLIBRA . . . . . . . . . . . . . . . . 7heparin . . . . . . . . . . . . . . . . . . . . 7hepatitis a vaccine susp . . . . . 50hepatitis b vaccine

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

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

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

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

HUMATIN . . . . . . . . . . . . . . . . . 31HUMIRA . . . . . . . . . . . . . . . . . . 32HUMULIN 70/30 . . . . . . . . . . 22HUMULIN N . . . . . . . . . . . . . . . 22HUMULIN R . . . . . . . . . . . . . . . 22HYCAMTIN . . . . . . . . . . . . . . . . 7HYCODAN . . . . . . . . . . . . . . . . 43hydralazine. . . . . . . . . . . . . . . . 11HYDREA . . . . . . . . . . . . . . . . . . 6hydrochlorothiazide . . . . . . 8-10hydrocodone ER . . . . . . . . . . . 13hydrocodone/

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

HOMATROP . . . . . . . . . . . 43hydrocortisone . . 17, 19-21, 36

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Index of Covered Drugshydrocortisone butyrate . . . . . 17hydrocortisone/aloe . . . . . . . . 17HYDROMET SYP . . . . . . . . . . 43hydromorphone . . . . . . . . . . . 13hydroxychloroquine . . . . .31, 32hydroxyurea . . . . . . . . . . . . . . . . 6hydroxyzine HCL . . . . . . . . . . . 20hydroxyzine pamoate . . . . . . . 20hyoscyamine sulfate . . . . . . . . 25hyoscyamine sulfate

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

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

COLD/SIN . . . . . . . . . . . . . 44ibuprofen . . . . . . . . . . . . . .13, 32icatibant . . . . . . . . . . . . . . . . . . 49ICLUSIG . . . . . . . . . . . . . . . . . . . 5idelalisib . . . . . . . . . . . . . . . . . . . 5IDHIFA . . . . . . . . . . . . . . . . . . . . 4ILARIS . . . . . . . . . . . . . . . . . . . 32imatinib mesylate . . . . . . . . . . . 5IMBRUVICA . . . . . . . . . . . . . . . . 4IMDUR . . . . . . . . . . . . . . . . . . . 11imipramine HCL . . . . . . . . . . . 39imiquimod 5% cream . . . . . . . 19IMITREX . . . . . . . . . . . . . . . . . . 14IMITREX 4 MG AND

6 MG INJ . . . . . . . . . . . . . . 14IMODIUM A-D . . . . . . . . . . . . . 24IMPAVIDO . . . . . . . . . . . . . . . . 28IMURAN . . . . . . . . . . . . . . . . 6, 32INCRELEX . . . . . . . . . . . . . . . . 23INCRUSE ELLIPTA . . . . . . . . . 45

indacaterol . . . . . . . . . . . . . . . . 45indapamide . . . . . . . . . . . . . . . 10INDERAL . . . . . . . . . . . . . . . 9, 14INDERAL LA . . . . . . . . . . . . . . . 9INDERIDE . . . . . . . . . . . . . . . . . 9indinavir . . . . . . . . . . . . . . . . . . 30INDOCIN . . . . . . . . . . . . . .13, 32indomethacin . . . . . . . . . .13, 32INFLAMASE FORTE . . . . . . . . 36influenza virus vaccine live

quadrivalent intranasal . . 50influenza virus vaccine

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

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

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

quadrivalent . . . . . . . . . . . . 51influenza virus vaccine split

quadrivalent pf . . . . . . . . . 51influenza virus vaccine tiss-cult

subunit quadrivalent. . . . . 51influenza virus vaccine types

a&b surface antigen . . . . . 51INGREZZA . . . . . . . . . . . . . . . . 16INLYTA . . . . . . . . . . . . . . . . . . . . 4inotersen inj . . . . . . . . . . . . . . 16insulin aspart protamine 70%/

insulin aspart 30% . . . . . . 22insulin glargine . . . . . . . . . . . . 22insulin glargine/lixisenatide . 21insulin human . . . . . . . . . . . . . 22insulin isophane . . . . . . . . . . . 22insulin isophane human . . . . . 22insulin isophane human 70%/

regular 30% . . . . . . . . . . . . 22insulin isophane/regular . . . . 22insulin lisopro pro/lispro . . . . 22insulin lisopro prot/lispro . . . . 22insulin lispro . . . . . . . . . . . . . . . 22

insulin pen needle . . . . . . . . . 50insulin regular . . . . . . . . . . . . . 22insulin syringes . . . . . . . . . . . . 50INTAL . . . . . . . . . . . . . . . . . . . . 45INTELENCE . . . . . . . . . . . . . . . 29interferon alfa-2b . . . . . . . . . 6, 29interferon gamma-1b . . . . . . . . 6INTRON A . . . . . . . . . . . . . . 6, 29INTUNIV . . . . . . . . . . . . . . . . . . 38INVEGA SUSTENNA . . . . . . . 41INVEGA TRINZA . . . . . . . . . . . 41INVIRASE . . . . . . . . . . . . . . . . . 31ipratropium . . . . . . . . 21, 45, 46ipratropium HFA . . . . . . . . . . . 45ipratropium nasal . . . . . . . . . . 21ipratropium/albuterol . . . .45, 46IRESSA . . . . . . . . . . . . . . . . . . . . 4ISENTRESS . . . . . . . . . . . . . . . 29ISENTRESS CHEWABLE . . . 29ISENTRESS HD . . . . . . . . . . . 29ISENTRESS SUSP . . . . . . . . . 29ISMO . . . . . . . . . . . . . . . . . . . . . 11isoniazid . . . . . . . . . . . . . . . . . . 27ISOPTO ATROPINE . . . . . . . . 37ISOPTO CARPINE . . . . . . . . . 37ISORDIL . . . . . . . . . . . . . . . . . . 11isosorbide dinitrate . . . . . . . . . 11ISOSORBIDE DINITRATE ER 11isosorbide dinitrate extended-

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

extended-release . . . . . . . 11isotretinoin . . . . . . . . . . . . . . . . 16itraconazole . . . . . . . . . . . . . . . 28ivacaftor . . . . . . . . . . . . . . . . . . 49ivermectin . . . . . . . . . . . . . . . . 26ivosidenib . . . . . . . . . . . . . . . . . 4ixazomib . . . . . . . . . . . . . . . . . . . 5

61



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

KK-DUR 10 . . . . . . . . . . . . . . . . . 49K-DUR 20 . . . . . . . . . . . . . . . . . 49K-LOR . . . . . . . . . . . . . . . . . . . . 49K-TAB M20 . . . . . . . . . . . . . . . 49KALETRA . . . . . . . . . . . . . . . . 30KALYDECO . . . . . . . . . . . . . . . 49KAYEXALATE . . . . . . . . . . . . . 11KAZANO . . . . . . . . . . . . . . . . . 22KEFLEX . . . . . . . . . . . . . . . . . . 27KENALOG . . . . . . . . . 17, 18, 21KENALOG IN ORABASE . . . . 21KEPPRA . . . . . . . . . . . . . . . . . . 15KERLONE . . . . . . . . . . . . . . . . . 9ketoconazole . . . . . . . 18, 19, 28ketoprofen . . . . . . . . . . . . .13, 32ketorolac . . . . . . . . . . . . . .13, 36ketorolac tromethamine . . . . . 13ketotifen . . . . . . . . . . . . . . . . . . 36KEVZARA . . . . . . . . . . . . . . . . 32KLONOPIN . . . . . . . . . . . .15, 38KLOR-CON 10 . . . . . . . . . . . . 49KLOR-CON 8 . . . . . . . . . . . . . 49KORLYM . . . . . . . . . . . . . . . . . 23KRINTAFEL . . . . . . . . . . . . . . . 31KUVAN . . . . . . . . . . . . . . . .23, 24KUVAN POWDER FOR

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

Llabetalol . . . . . . . . . . . . . . . . . . . 9LAC-HYDRIN . . . . . . . . . . . . . . 19lacosamide . . . . . . . . . . . . . . . 15LACTINEX . . . . . . . . . . . . . . . . 26LACTINOL . . . . . . . . . . . . . . . . 19lactulose . . . . . . . . . . . . . . . . . . 24

LAMICTAL . . . . . . . . . . . . . . . . 15LAMICTAL CD CHEW TAB . . 15LAMICTAL STARTER KIT . . . 15LAMISIL . . . . . . . . . . . . . . .18, 28LAMISIL AT . . . . . . . . . . . . . . . 18lamivudine . . . . . . . . . . . . . 29-31lamivudine/tenofovir disoproxil

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

tab . . . . . . . . . . . . . . . . . . . . 15lamotrigine starter kit . . . . . . . 15lancets . . . . . . . . . . . . . . . . . . . 50LANOXIN . . . . . . . . . . . . . . . . . . 8lansoprazole . . . . . . . . . . . . . . 25lansoprazole delayed-release 25lapatinib ditosylate . . . . . . . . . . 5LARIAM . . . . . . . . . . . . . . . . . . 31larotrectinib . . . . . . . . . . . . . . . . 5LASIX . . . . . . . . . . . . . . . . . . . . 10latanoprost . . . . . . . . . . . . . . . . 37leflunomide . . . . . . . . . . . . . . . 32lenalidomide . . . . . . . . . . . . . . . 6lenvatinib . . . . . . . . . . . . . . . . . . 5LENVIMA . . . . . . . . . . . . . . . . . . 5LETAIRIS . . . . . . . . . . . . . . . . . 11letrozole . . . . . . . . . . . . . . . . . . . 5leucovorin . . . . . . . . . . . . . . . . . 5LEUKERAN . . . . . . . . . . . . . . . . 4LEUKINE . . . . . . . . . . . . . . . . . . 7leuprolide . . . . . . . . . . . . . . . . 5, 6LEUPROLIDE ACETATE . . . . . 6levalbuterol HCl . . . . . . . . . . . . 46LEVAQUIN . . . . . . . . . . . . . . . . 27levetiracetam . . . . . . . . . . . . . . 15levobunolol . . . . . . . . . . . . . . . 36levocetirizine . . . . . . . . . . . . . . 20levofloxacin . . . . . . . . . . . . . . . 27levonorgestrel . . . . . . . . . .33, 34

levonorgestrel/EE . . . . . . .33, 34levothyroxine . . . . . . . . . . . . . . 23LEVOXYL . . . . . . . . . . . . . . . . . 23LEVSIN . . . . . . . . . . . . . . . . . . . 25LEVSINEX . . . . . . . . . . . . . . . . 25LEXAPRO . . . . . . . . . . . . . . . . 39LEXIVA . . . . . . . . . . . . . . . . . . . 30LIBRIUM . . . . . . . . . . . . . . . . . . 38LIDAMANTEL . . . . . . . . . . . . . 19LIDEX . . . . . . . . . . . . . . . . . . . . 18LIDEX E . . . . . . . . . . . . . . . . . . 18lidocaine . . . . . . . . . . . . . . .19, 21lidocaine patch . . . . . . . . . . . . 19lidocaine viscous . . . . . . . . . . 21lidocaine/prilocaine . . . . . . . . 19LIDODERM . . . . . . . . . . . . . . . 19lifitegrast . . . . . . . . . . . . . . . . . 35linezolid . . . . . . . . . . . . . . . . . . 31liothyronine . . . . . . . . . . . . . . . 23LIPITOR . . . . . . . . . . . . . . . . . . 11liraglutide . . . . . . . . . . . . . . . . 22lisinopril . . . . . . . . . . . . . . . . 8, 72lisinopril/hydrochlorothiazide . 8lithium carbonate . . . . . . . . . . 39lithium carbonate extended-

release . . . . . . . . . . . . . . . . 39LITHOBID . . . . . . . . . . . . . . . . . 39lixisenatide . . . . . . . . . . . . . . . . 22LMX-4 . . . . . . . . . . . . . . . . . . . . 19LO/OVRAL . . . . . . . . . . . . . . . . 34LOCOID . . . . . . . . . . . . . . . . . . 17LODINE . . . . . . . . . . . . . . .12, 32LOESTRIN 1/20 . . . . . . . . . . . 34LOESTRIN 1.5/30 . . . . . . . . . 34LOESTRIN FE 1/20 . . . . . . . . 34LOESTRIN FE 1.5/30 . . . . . . . 34LOFIBRA . . . . . . . . . . . . . . . . . 10LOHIST-D . . . . . . . . . . . . . . . . . 42LOKELMA . . . . . . . . . . . . . . . . 11LOMOTIL . . . . . . . . . . . . . . . . . 24

62


Index of Covered Drugslomustine . . . . . . . . . . . . . . . . . . 4LONITEN . . . . . . . . . . . . . . . . . 12LONSURF . . . . . . . . . . . . . . . . . 4loperamide . . . . . . . . . . . . . . . . 24LOPID . . . . . . . . . . . . . . . . . . . . 10LOPIDINE . . . . . . . . . . . . . . . . 37lopinavir/ritonavir . . . . . . . . . . 30LOPRESSOR . . . . . . . . . . . . . . . 9loratadine . . . . . . . . . . . . . . . . . 20lorazepam . . . . . . . . . . . . . . . . 38LORCET . . . . . . . . . . . . . . . . . . 13LORTAB . . . . . . . . . . . . . . . . . . 13LORTAB ELIXIR . . . . . . . . . . . 13losartan . . . . . . . . . . . . . . . . . . . 8losartan/HCTZ . . . . . . . . . . . . . 8LOTENSIN . . . . . . . . . . . . . . . . . 8LOTENSIN HCT . . . . . . . . . . . . 8LOTRIMIN AF . . . . . . . . . . . . . 18LOTRISONE . . . . . . . . . . . . . . . 18lovastatin . . . . . . . . . . . . . . . . . 11LOVAZA . . . . . . . . . . . . . . . . . . 11LOVENOX . . . . . . . . . . . . . . . . . 7loxapine . . . . . . . . . . . . . . . . . . 41LOXITANE . . . . . . . . . . . . . . . . 41LOZOL . . . . . . . . . . . . . . . . . . . 10LUDIOMIL . . . . . . . . . . . . . . . . 39lumacaftor/ivacaftor . . . . . . . . 49LUPRON . . . . . . . . . . . . . . . . . . 5LUPRON DEPOT . . . . . . . . . . . 5LUPRON DEPOT 6-MONTH . . 5LUPRON DEPOT-PED . . . . . . . 5LURIDE . . . . . . . . . . . . . . . . . . . 47LURIDE LOZI-TABS. . . . . . . . . 47lusutrombopag . . . . . . . . . . . . . 7LUVOX . . . . . . . . . . . . . . . . . . . 38LYNPARZA . . . . . . . . . . . . . . . . 6LYSODREN . . . . . . . . . . . . . . . . 6LYSTEDA . . . . . . . . . . . . . . . . . 35

MM-CLEAR WC . . . . . . . . . . . . . 42M-M-R II . . . . . . . . . . . . . . . . . . 51MAALOX . . . . . . . . . . . . . . . . . 25macitentan . . . . . . . . . . . . . . . . 11MACROBID . . . . . . . . . . . . . . . 31MACRODANTIN . . . . . . . . . . . 31MAG-OX . . . . . . . . . . . . . . . . . . 47magnesium citrate soln . . . . . 24magnesium oxide . . . . . . . . . . 47MAPAP COLD TAB . . . . . . . . 44maprotiline . . . . . . . . . . . . . . . . 39maraviroc . . . . . . . . . . . . . . . . . 31MATERNA . . . . . . . . . . . . . . . . 48MATULANE . . . . . . . . . . . . . . . . 7MAVIK . . . . . . . . . . . . . . . . . . . . . 8MAVYRET . . . . . . . . . . . . . . . . 28MAXALT . . . . . . . . . . . . . . . . . . 14MAXALT MLT . . . . . . . . . . . . . 14MAXITROL. . . . . . . . . . . . . . . . 36MAXZIDE . . . . . . . . . . . . . . . . . 10MAYZENT . . . . . . . . . . . . . . . . 14measles, mumps & rubella

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

acetate . . . . . . . . . . . . .33, 35mefloquine . . . . . . . . . . . . . . . . 31MEGACE . . . . . . . . . . . . . . . . . . 6megestrol acetate . . . . . . . . . . . 6MEKINIST . . . . . . . . . . . . . . . . . 5meloxicam . . . . . . . . . . . . .13, 32melphalan . . . . . . . . . . . . . . . . . 4memantine . . . . . . . . . . . . . . . . 12MENACTRA . . . . . . . . . . . . . . . 51meningococcal (a, c, y, and

w-135) . . . . . . . . . . . . . . . . 51

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

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

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

extended-release . . . . . . . 25mesalamine supp . . . . . . . . . 26mesna . . . . . . . . . . . . . . . . . . . 5, 6MESNEX . . . . . . . . . . . . . . . . 5, 6MESTINON . . . . . . . . . . . . . . . 14MESTINON TIMESPAN . . . . . 14METADATE CD . . . . . . . . . . . . 38METADATE ER . . . . . . . . . . . . 38metformin . . . . . . . . . . . . . .22, 23metformin ER . . . . . . . . . . . . . 23metformin/glyburide . . . . . . . . 23methazolamide . . . . . . . . . . . . 37methenamine hippurate . . . . . 46METHERGINE . . . . . . . . . .23, 35methimazole . . . . . . . . . . . . . . 23methocarbamol . . . . . . . . . . . . 33methotrexate . . . . . . . . . . . . . . 32methyldopa . . . . . . . . . . . . . . . 11methylergonovine . . . . . . .23, 35methylphenidate . . . . . . . . . . . 38methylphenidate extended-

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

24hr . . . . . . . . . . . . . . . . . . 38methylprednisolone . . . . . . . . 21metipranolol . . . . . . . . . . . . . . . 36metoclopramide . . . . . . . . . . . 24metolazone . . . . . . . . . . . . . . . 10

63



metoprolol . . . . . . . . . . . . . . . . . 9metoprolol succinate . . . . . . . . 9METROCREAM . . . . . . . . . . . 18METROGEL . . . . . . . . . . . . . . . 18METROGEL-VAGINAL . . . . . . 35METROLOTION . . . . . . . . . . . 18metronidazole . . . . . . 18, 31, 35MEVACOR . . . . . . . . . . . . . . . . 11mexiletine . . . . . . . . . . . . . . . . . . 9MEXITIL . . . . . . . . . . . . . . . . . . . 9MIACALCIN . . . . . . . . . . . . . . . 23MICATIN . . . . . . . . . . . . . . . . . . 18miconazole . . . . . . . . . . . .18, 35MICRO-K 10 . . . . . . . . . . . . . . 49MICRONASE . . . . . . . . . . . . . . 23MICROZIDE . . . . . . . . . . . . . . . 10MIDAMOR . . . . . . . . . . . . . . . . 10midodrine . . . . . . . . . . . . . . . . . 11midostaurin . . . . . . . . . . . . . . . . 5mifepristone . . . . . . . . . . . . . . . 23MILLIPRED . . . . . . . . . . . . . . . 21miltefosine . . . . . . . . . . . . . . . . 28MINIPRESS . . . . . . . . . . . . . . . . 8MINOCIN . . . . . . . . . . . . . . . . . 28minocycline . . . . . . . . . . . . . . . 28minoxidil . . . . . . . . . . . . . . . . . . 12MINUTUSS DR SYP . . . . . . . . 43MIRALAX . . . . . . . . . . . . . . . . . 24MIRAPEX . . . . . . . . . . . . . . . . . 15MIRCETTE . . . . . . . . . . . . . . . . 33mirtazapine . . . . . . . . . . . . . . . 39misoprostol . . . . . . . . . . . . . . . 26MITIGARE . . . . . . . . . . . . . . . . 33mitotane . . . . . . . . . . . . . . . . . . . 6MOBIC . . . . . . . . . . . . . . . .13, 32MODICON . . . . . . . . . . . . . . . . 34MODURETIC . . . . . . . . . . . . . . 10mometasone . . . . . . . . . . .17, 45mometasone furoate . . . . . . . 17MONISTAT 3 . . . . . . . . . . . . . . 35

MONISTAT-DERM . . . . . . . . . . 18MONOPRIL . . . . . . . . . . . . . . . . 8MONOPRIL-HCT . . . . . . . . . . . . 8montelukast . . . . . . . . . . . . . . . 46morphine . . . . . . . . . . . . . . . . . 13morphine extended-release . . 13MOTEGRITY . . . . . . . . . . . . . . 24MOTRIN . . . . . . . . . . . . . . .13, 32MOVANTIK . . . . . . . . . . . . . . . 24MOZOBIL . . . . . . . . . . . . . . . . . . 7MS CONTIN . . . . . . . . . . . . . . . 13MSIR . . . . . . . . . . . . . . . . . . . . . 13MUCINEX . . . . . . . . . . . . . . . . . 43MUCINEX D . . . . . . . . . . . . . . . 43MUCINEX DM . . . . . . . . . . . . . 43MUCOMYST . . . . . . . . . . . . . . 49MULPLETA . . . . . . . . . . . . . . . . 7MULTI SYMPTOM TAB COLD

RLF . . . . . . . . . . . . . . . . . . . 44multiple vitamin chewable tablet

and drops . . . . . . . . . . . . . 47multivitamins/fluoride/±iron . 47multivitamins/minerals . . . . . . 47mupirocin . . . . . . . . . . . . . . . . . 17MURO 128 . . . . . . . . . . . . . . . 37MYAMBUTOL . . . . . . . . . . . . . 27MYCELEX . . . . . . . . . . . . .18, 28MYCOBUTIN . . . . . . . . . . . . . . 28mycophenolate mofetil . . . . . . . 6mycophenolate sodium . . . . . . 6MYCOSTATIN . . . . . . . . . .18, 28MYFORTIC. . . . . . . . . . . . . . . . . 6MYLANTA . . . . . . . . . . . . . . . . 25MYLERAN . . . . . . . . . . . . . . . . . 4MYORISAN . . . . . . . . . . . . . . . 16MYSOLINE . . . . . . . . . . . . . . . . 16mytesi . . . . . . . . . . . . . . . . . . . . 24

Nnabumetone . . . . . . . . . . . . . . 13naloxone . . . . . . . . . . . . . . .14, 40

naloxegol . . . . . . . . . . . . . . . . . 24NALOXONE INJ . . . . . . . . . . . 40naltrexone . . . . . . . . . . . . .38, 40NAMENDA . . . . . . . . . . . . . . . . 12naphazoline HCL . . . . . . . . . . 36naphazoline/glycerin . . . . . . . 36NAPROSYN . . . . . . . . . . . .13, 33naproxen . . . . . . . . . . . . . .13, 33naproxen delayed release 13, 33naratriptan . . . . . . . . . . . . . . . . 14NARCAN NASAL SPRAY . . . 40NASACORT ALLERGY

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

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

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

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

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

hydrocortisone . . . . . .20, 36NEORAL . . . . . . . . . . . . . . . . . . 6NEOSPORIN . . . . . . . . . . .17, 37NEPHROCAPS . . . . . . . . . . . . 48NEPTAZANE . . . . . . . . . . . . . . 37NESINA . . . . . . . . . . . . . . . . . . 22NESTABS . . . . . . . . . . . . . . . . . 48NEULASTA . . . . . . . . . . . . . . . . 7NEUMEGA . . . . . . . . . . . . . . . . . 7NEURONTIN . . . . . . . . . . . . . . 15

64


Index of Covered DrugsNEUTROGENA OIL FREE

ACNE WASH . . . . . . . . . . . 17nevirapine . . . . . . . . . . . . . . . . 29nevirapine ER . . . . . . . . . . . . . 29NEXAVAR . . . . . . . . . . . . . . . . . 5NEXIUM 24HR OTC . . . . . . . 25NEXIUM DELAYED RELEASE

PACKET . . . . . . . . . . . . . . 25niacin . . . . . . . . . . . . . . . . . . . . 11niacin extended-release . . . . . 11NIACOR . . . . . . . . . . . . . . . . . . 11NIASPAN . . . . . . . . . . . . . . . . . 11NICODERM CQ . . . . . . . . . . . 41NICORETTE OTC . . . . . . . . . . 41nicotine . . . . . . . . . . . . . . . . . . . 41nicotine polacrilex gum . . . . . 41nicotine polacrilex lozenge . . 41nifedipine . . . . . . . . . . . . . . . . . . 9nifedipine extended-release . . 9nilotinib . . . . . . . . . . . . . . . . . . . . 5nimodipine . . . . . . . . . . . . . . . . . 9NIMOTOP. . . . . . . . . . . . . . . . . . 9NINLARO . . . . . . . . . . . . . . . . . . 5niraparib . . . . . . . . . . . . . . . . . . . 6nitazoxanide tablet . . . . . . . . . 28 nitisinone . . . . . . . . . . . . . . . . . 23NITRO-DUR . . . . . . . . . . . . . . . 11nitrofurantoin

extended-release . . . . . . . 31nitrofurantoin macrocrystals . 31nitrofurantoin susp . . . . . . . . . 31nitroglycerin . . . . . . . . . . . . . . . 11NITROSTAT . . . . . . . . . . . . . . . 11NITYR . . . . . . . . . . . . . . . . . . . . 23NIX CREME RINSE . . . . . . . . . 19NIZORAL . . . . . . . . . . 18, 19, 28NIZORAL SHAMPOO. . . . . . . 19NOCDURNA . . . . . . . . . . . . . . 23NOLVADEX . . . . . . . . . . . . . . . . 5NORCO . . . . . . . . . . . . . . . . . . 13NORDETTE . . . . . . . . . . . . . . . 34

norelgestromin/EE . . . . . . . . . 34norethindrone . . . . . . . . . . 33-35norethindrone acetate . . .34, 35norethindrone acetate/EE . . . 34norethindrone acetate/EE/

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

OOCEAN NASAL SPRAY . . . . . 21octreotide . . . . . . . . . . . . . . . . . . 6OCUFEN . . . . . . . . . . . . . . . . . 36OCUFLOX . . . . . . . . . . . . . . . . 37ODEFSEY. . . . . . . . . . . . . . . . . 30ODOMZO . . . . . . . . . . . . . . . . . . 7ofloxacin . . . . . . . . . . . 20, 27, 37OGEN . . . . . . . . . . . . . . . . . . . . 35olanzapine . . . . . . . . . . . . . . . . 41olaparib . . . . . . . . . . . . . . . . . . . 6olodaterol . . . . . . . . . . . . . . . . . 45OLUMIANT . . . . . . . . . . . . . . . 32omadacycline . . . . . . . . . . . . . 28

omalizumab . . . . . . . . . . . . . . . 45ombitasvir/ paritaprevir/

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

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

65



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

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

Ppalbociclib . . . . . . . . . . . . . . . . . 5paliperidone . . . . . . . . . . . . . . . 41palivizumab . . . . . . . . . . . . . . . 31PAMELOR . . . . . . . . . . . . . . . . 39panobinostat . . . . . . . . . . . . . . . 4PANRETIN . . . . . . . . . . . . . . . . . 6pantoprazole . . . . . . . . . . . . . . 25PARAFON FORTE DSC . . . . . 33PARNATE . . . . . . . . . . . . . . . . . 39paromomycin . . . . . . . . . . . . . 31paroxetine . . . . . . . . . . . . . . . . 39pasireotide . . . . . . . . . . . . . . . . . 6patiromer . . . . . . . . . . . . . . . . . 11PAXIL . . . . . . . . . . . . . . . . . . . . 39pazopanib . . . . . . . . . . . . . . . . . 5PEDIACARE LIQ MULTI-SY . . 44PEDIALYTE . . . . . . . . . . . . . . . 47PEDIAPRED . . . . . . . . . . . . . . . 21PEDIAZOLE . . . . . . . . . . . . . . . 27peg 3350/electrolytes . . . . . . 24peg 3350/sodium bicarbonate/

sodium chloride . . . . . . . . 24

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

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

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

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

brompheniramine/dextromethorphan . . . . . . 43

phenylephrine/chlorpheniramine/ dextromethorphan . . .43, 44

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

phenylephrine/dextromethorphan . . . . . . 44

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

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

phenylephrine/guaifenesin . . 44phenylephrine/pyrilamine

w/hydrocodone . . . . . . . . 44PHENYTEK . . . . . . . . . . . . . . . 16phenytoin . . . . . . . . . . . . . . . . . 16phenytoin sodium extended . 16PHILLIPS COLON HEALTH . 26PHOS-FLUR . . . . . . . . . . . . . . 47phytonadione. . . . . . . . . . . . . . 47pilocarpine . . . . . . . . . . . . .21, 37pimecrolimus . . . . . . . . . . . . . 19pimozide . . . . . . . . . . . . . . . . . 41PIN-X . . . . . . . . . . . . . . . . . . . . . 27PIQRAY . . . . . . . . . . . . . . . . . . . 4piroxicam . . . . . . . . . . . . . .13, 33PLAN B ONE STEP . . . . . . . . 33PLAQUENIL . . . . . . . . . . . .31, 32PLAVIX . . . . . . . . . . . . . . . . . . . . 7plecanatide . . . . . . . . . . . . . . . 24PLEGRIDY . . . . . . . . . . . . . . . . 14PLENDIL . . . . . . . . . . . . . . . . . . 9plerixafor . . . . . . . . . . . . . . . . . . 7PLETAL . . . . . . . . . . . . . . . . . . . 7pneumococcal 13-valent

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

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

66



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

release . . . . . . . . . . . . . . . . 49povidone-iodine . . . . . . . . . . . 31praluent . . . . . . . . . . . . . . . . . . 11pramipexole . . . . . . . . . . . . . . . 15PRANDIN . . . . . . . . . . . . . . . . . 23prasugrel . . . . . . . . . . . . . . . . . . 7praziquantel . . . . . . . . . . . . . . . 26prazosin . . . . . . . . . . . . . . . . . . . 8PRECOSE . . . . . . . . . . . . . . . . 22PRED FORTE . . . . . . . . . . . . . 36prednicarbate . . . . . . . . . . . . . 17prednisolone . . . . . . . . . . .21, 36prednisolone acetate . . . . . . . 36prednisolone phosphate . . . . 36prednisolone sodium

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

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

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

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

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

FA . . . . . . . . . . . . . . . . . . . . 48prenatal vitamins w/folic acid 48prenatal w/o A w/FE carbonyl-

FE gluc-DSS-FA . . . . . . . . 48

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

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

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

cap . . . . . . . . . . . . . . . . . . . 34PROGRAF . . . . . . . . . . . . . . . . . 6PROLIXIN . . . . . . . . . . . . . . . . . 41PROLIXIN DECANOATE . . . . 41PROMACTA . . . . . . . . . . . . . . . . 7promethazine . . . . . . 24, 42, 43PROMETHAZINE SYP DM . . 43PROMETHAZINE VC

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

W/CODEINE . . . . . . . . . . . 42PROMETRIUM . . . . . . . . . . . . 34propafenone . . . . . . . . . . . . . . . 9propranolol . . . . . . . . . . . . . 9, 14propranolol ER 24HR . . . . . . . 9propranolol/HCTZ . . . . . . . . . . 9propylthiouracil . . . . . . . . . . . . 23PROSCAR . . . . . . . . . . . . . . . . 46PROTONIX . . . . . . . . . . . . . . . . 25

PROTOPIC 0.03% . . . . . . . . . 19PROTOPIC 0.1% . . . . . . . . . . . 20PROVENTIL . . . . . . . . . . . . . . . 45PROVERA . . . . . . . . . . . . . . . . 35PROZAC . . . . . . . . . . . . . . . . . 39prucalopride . . . . . . . . . . . . . . 24PRUET DHA PAK SETONET

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

dexchlorphen tan/DM tan 45pseudoephedrine/

acetaminophen/dextromethorphan . . . . . . 44

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

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

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

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

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

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

67



QUINIDINE GLUCONATE EXT-REL . . . . . . . . . . . . . . . . . . . . 9

quinidine gluconate extended-release . . . . . . . . . . . . . . . . . 9

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

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

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

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

MEDICINE . . . . . . . . . . . . . 27REGLAN . . . . . . . . . . . . . . . . . 24regorafenib . . . . . . . . . . . . . . . . 5REGRANEX . . . . . . . . . . . . . . . 19RELAFEN . . . . . . . . . . . . . . . . . 13RELENZA. . . . . . . . . . . . . . . . . 29RELION 70/30 . . . . . . . . . . . . 22RELION N . . . . . . . . . . . . . . . . 22RELION R . . . . . . . . . . . . . . . . 22REMERON . . . . . . . . . . . . . . . . 39RENVELA . . . . . . . . . . . . . . . . 49repaglinide . . . . . . . . . . . . . . . . 23REPATHA . . . . . . . . . . . . . . . . 11REQUIP . . . . . . . . . . . . . . . . . . 15

RESCRIPTOR . . . . . . . . . . . . . 29RESPERAL-DM . . . . . . . . . . . . 42RESTORIL . . . . . . . . . . . . . . . . 40RETACRIT . . . . . . . . . . . . . . . . . 7RETIN-A . . . . . . . . . . . . . . . . . . 17RETROVIR . . . . . . . . . . . . . . . . 30REVATIO . . . . . . . . . . . . . . . . . 11REVIA . . . . . . . . . . . . . . . . .38, 40REVLIMID . . . . . . . . . . . . . . . . . 6REYATAZ . . . . . . . . . . . . . . . . . 30REYATAZ POWDER

PACKET . . . . . . . . . . . . . . . 30ribavirin . . . . . . . . . . . . . . . . . . . 29RID SHAMPOO . . . . . . . . . . . . 19rifabutin . . . . . . . . . . . . . . . . . . 28RIFADIN . . . . . . . . . . . . . . . . . . 27rifampin . . . . . . . . . . . . . . . . . . 27rilpivirine . . . . . . . . . . . . . . . 29-31RILUTEK . . . . . . . . . . . . . . . . . 12riluzole . . . . . . . . . . . . . . . . . . . 12rimantadine . . . . . . . . . . . . . . . 29riociguat . . . . . . . . . . . . . . . . . . 11RISA-BID . . . . . . . . . . . . . . . . . 26RISAQUAD . . . . . . . . . . . . . . . . 26RISPERDAL . . . . . . . . . . . . . . . 41RISPERDAL CONSTA . . . . . . 41RISPERDAL SOLUTION . . . . 41risperidone . . . . . . . . . . . . . . . . 41risperidone inj . . . . . . . . . . . . . 41risperidone oral soln . . . . . . . . 41RITALIN . . . . . . . . . . . . . . . . . . 38RITALIN LA . . . . . . . . . . . . . . . 38ritonavir . . . . . . . . . . . . . . . . 28-31rivastigmine . . . . . . . . . . . . . . . 12rizatriptan . . . . . . . . . . . . . . . . . 14RMS . . . . . . . . . . . . . . . . . . . . . 13ROBAXIN . . . . . . . . . . . . . . . . . 33ROBINUL . . . . . . . . . . . . . . . . . 25ROBITUSSIN . . . . . . . . . . . 42-44ROBITUSSIN CF . . . . . . . . . . . 43

ROBITUSSIN DM . . . . . . . . . . 43ROBITUSSIN LIQ CGH/

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

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

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

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

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

CNG . . . . . . . . . . . . . . . . . . 43ROBITUSSIN SYP MAX-ST . . 43ROCALTROL . . . . . . . . . . . . . . 47ROCALTROL SOLUTION . . . 47RONDEC DM . . . . . . . . . .43, 44RONDEC DM DROPS . . . . . . 44RONDEC DROPS . . . . . . . . . . 42RONDEC SYRUP . . . . . . . . . . 42ropinirole . . . . . . . . . . . . . . . . . 15ROWASA . . . . . . . . . . . . . . . . . 25ROXICODONE . . . . . . . . . . . . 13RUBRACA . . . . . . . . . . . . . . . . . 7rucaparib . . . . . . . . . . . . . . . . . . 7rufinamide . . . . . . . . . . . . . . . . 16ruxolitinib . . . . . . . . . . . . . . . . . . 5RUZURGI . . . . . . . . . . . . . . . . 33RYDAPT . . . . . . . . . . . . . . . . . . . 5RYNA-12 S . . . . . . . . . . . . . . . 45RYNATAN PEDIATRIC

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

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

SSABRIL . . . . . . . . . . . . . . . . . . . 16sacubitril/valsartan . . . . . . . . . . 8

68


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

siponimod fumarate . . . . . . . 14sirolimus . . . . . . . . . . . . . . . . . . . 6SIRTURO . . . . . . . . . . . . . . . . . 31sodium bicarbonate . . . . . . . 25sodium chloride for nebulizer 49sodium chloride hypertonic . 37sodium citrate/citric acid . . . . 46sodium phenylbutyrate . . . . . 50sodium polystyrene sulfonate 11sodium zirconium

cyclosilicate . . . . . . . . . . . 11sofosbuvir/velpatasvir/

voxilaprevir . . . . . . . . . . . . 29SOLIQUA . . . . . . . . . . . . . . . . 21somatropin . . . . . . . . . . . . . . . . 23SOMAVERT . . . . . . . . . . . . . . . 23SONATA . . . . . . . . . . . . . . . . . . 40sonidegib . . . . . . . . . . . . . . . . . . 7sorafenib . . . . . . . . . . . . . . . . . . 5SORIATANE . . . . . . . . . . . . . . . 18sotalol . . . . . . . . . . . . . . . . . . . . . 9sotalol AF . . . . . . . . . . . . . . . . . . 9spacers . . . . . . . . . . . . . . . . . . . 50spinosad . . . . . . . . . . . . . . . . . 19spironolactone. . . . . . . . . . . . . 10spironolactone/

hydrochlorothiazide . . . . . 10SPORANOX . . . . . . . . . . . . . . . 28SPRYCEL . . . . . . . . . . . . . . . . . . 4STADOL . . . . . . . . . . . . . . . . . . 13STARLIX . . . . . . . . . . . . . . . . . . 23STATUSS DM SYP . . . . . . . . . 43stavudine . . . . . . . . . . . . . . . . . 30STEGLATRO . . . . . . . . . . . . . . 22STELAZINE . . . . . . . . . . . . . . . 41STIOLTO RESPIMAT . . . . . . . 45STIVARGA . . . . . . . . . . . . . . . . . 5STRATTERA . . . . . . . . . . . . . . 38STRENSIQ . . . . . . . . . . . . . . . . 23STRIBILD . . . . . . . . . . . . . . . . . 31

STRIVERDI RESPIMAT . . . . . 45STROMECTOL . . . . . . . . . . . . 26SUBOXONE . . . . . . . . . . . . . . . 40SUBUTEX . . . . . . . . . . . . . . . . 40succimer . . . . . . . . . . . . . . . . . 49sucralfate . . . . . . . . . . . . . . . . . 25sulcralfate . . . . . . . . . . . . . . . . . 25SULFACET-R . . . . . . . . . . . . . . 17sulfacetamide . . . . . . 17, 36, 37sulfacetamide/pred phos . . . 36sulfacetamide/sulfur . . . . . . . . 17sulfamethoxazole/

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

delayed-release . . . . . .26, 32sulindac . . . . . . . . . . . . . . .13, 33SUMADAN WASH . . . . . . . . . 17sumatriptan . . . . . . . . . . . . . . . 14sunitinib . . . . . . . . . . . . . . . . . . . 5SUSTIVA . . . . . . . . . . . . . . . . . . 29SUTENT . . . . . . . . . . . . . . . . . . . 5SYLATRON . . . . . . . . . . . . . . . . 6SYMDEKO . . . . . . . . . . . . . . . 49SYMFI . . . . . . . . . . . . . . . . . . . . 30SYMFI LO . . . . . . . . . . . . . . . . . 30SYMJEPI . . . . . . . . . . . . . . . . . 49SYMMETREL . . . . . . . . . .15, 29SYNAGIS . . . . . . . . . . . . . . . . . 31SYNALAR . . . . . . . . . . . . . . . . 17SYNTHROID . . . . . . . . . . . . . . 23

TT-STAT . . . . . . . . . . . . . . . . . . . 16TABLOID . . . . . . . . . . . . . . . . . . 4tacrolimus . . . . . . . . . . 6, 19, 20tafamidis . . . . . . . . . . . . . . . . . 12tafamidis meglumine . . . . . . . 12tafenoquine . . . . . . . . . . . . . . . 31TAFINLAR . . . . . . . . . . . . . . . . . 4

69



TAGAMET . . . . . . . . . . . . . . . . 25TALWIN NX . . . . . . . . . . . . . . . 14TAMBOCOR . . . . . . . . . . . . . . . 9TAMIFLU . . . . . . . . . . . . . . . . . 29tamoxifen . . . . . . . . . . . . . . . . . . 5tamsulosin . . . . . . . . . . . . . . . . 46TANAFED DMX

SUSPENSION . . . . . . . . . . 45TAPAZOLE . . . . . . . . . . . . . . . . 23TARCEVA . . . . . . . . . . . . . . . . . . 4TARGRETIN . . . . . . . . . . . . . . . . 6TASIGNA . . . . . . . . . . . . . . . . . . 5TASMAR . . . . . . . . . . . . . . . . . . 15TECFIDERA . . . . . . . . . . . . . . . 14teduglutide . . . . . . . . . . . . . . . . 26TEGRETOL . . . . . . . . . . . . . . . 15TEGRETOL-XR . . . . . . . . . . . . 15TEGSEDI . . . . . . . . . . . . . . . . . 12temazepam . . . . . . . . . . . . . . . 40TEMODAR . . . . . . . . . . . . . . . . . 4TEMOVATE . . . . . . . . . . . . . . . 18TEMOVATE E . . . . . . . . . . . . . 18temozolomide . . . . . . . . . . . . . . 4TENEX . . . . . . . . . . . . . . . . . . . . 8TENIVAC . . . . . . . . . . . . . . . . . 51tenofovir . . . . . . . . . . . . . . .30, 31TENORETIC . . . . . . . . . . . . . . . 9TENORMIN . . . . . . . . . . . . . . . . 9TERAZOL 3/7 . . . . . . . . . . . . . 35terazosin . . . . . . . . . . . . . . . . 8, 46terbinafine . . . . . . . . . . . . .18, 28terconazole . . . . . . . . . . . . . . . 35teriflunomide . . . . . . . . . . . . . . 14TESSALON . . . . . . . . . . . . . . . 41TESTOSTERONE 1%

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

packet, and pump bottle . 21

tet tox-diph-acell pertuss ad . 51TET/DIP TOX INJ . . . . . . . . . . 51tetanus immune globulin

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

(td) . . . . . . . . . . . . . . . . . . . 51tetrabenazine . . . . . . . . . . . . . . 16tetrahydrozoline/zinc sulfate . 36tezacaftor/ivcaftor . . . . . . . . . 49thalidomide . . . . . . . . . . . . . . . . 6THALOMID . . . . . . . . . . . . . . . . 6THEOCHRON . . . . . . . . . . . . . 46theophylline . . . . . . . . . . . . . . . 46theophylline

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

tolterodine . . . . . . . . . . . . . . . . 46TOPAMAX . . . . . . . . . . . . . . . . 16TOPAMAX SPRINKLE . . . . . . 16topiramate . . . . . . . . . . . . . . . . 16topiramate sprinkle caps . . . . 16topotecan . . . . . . . . . . . . . . . . . . 7TOPROL XL . . . . . . . . . . . . . . . . 9TORADOL . . . . . . . . . . . . . . . . 13toremifene . . . . . . . . . . . . . . . . . 5torsemide . . . . . . . . . . . . . . . . . 10TRACLEER . . . . . . . . . . . . . . . 11tramadol . . . . . . . . . . . . . . . . . . 12trametinib . . . . . . . . . . . . . . . . . . 5TRANDATE . . . . . . . . . . . . . . . . 9trandolapril . . . . . . . . . . . . . . . . . 8tranexamic acid . . . . . . . . . . . . 35TRANXENE . . . . . . . . . . . . . . . 38tranylcypromine . . . . . . . . . . . . 39trazodone . . . . . . . . . . . . . . . . . 40TRENTAL . . . . . . . . . . . . . . . . . . 7tretinoin . . . . . . . . . . . . . . . . 7, 17TRI RX . . . . . . . . . . . . . . . . . . . 48TRI-FED X. . . . . . . . . . . . . . . . . 45TRI-NORINYL . . . . . . . . . . . . . 34TRI-VI-FLOR . . . . . . . . . . . . . . . 48TRI-VI-SOL . . . . . . . . . . . . . . . . 48triamcinolone . . . . 17, 18, 20, 21triamcinolone acetonide .17, 18triamcinolone nasal spray . . . 20triamterene/

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

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Index of Covered Drugstrimethobenzamide . . . . . . . . 24trimethoprim . . . . . . . 28, 31, 37TRIOTANN PEDIATRIC

SUSP . . . . . . . . . . . . . . . . . 42tripolidine/pseudoephedrine 45TRIPROL/PSE SYP . . . . . . . . 45TRIUMEQ . . . . . . . . . . . . . . . . . 31TRIVORA . . . . . . . . . . . . . . . . . 34TRIZIVIR . . . . . . . . . . . . . . . . . . 30trospium . . . . . . . . . . . . . . . . . . 46TRULANCE . . . . . . . . . . . . . . 24TRULICITY . . . . . . . . . . . . . . . 22TRUSOPT . . . . . . . . . . . . . . . . 36TRUST NATALCARE

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

UULORIC . . . . . . . . . . . . . . . . . . 33ULTRA . . . . . . . . . . . . . . . . . . . 22ULTRA 2, ULTRAMINI . . . . . . 22ULTRAM . . . . . . . . . . . . . . . . . . 12ULTRAVATE . . . . . . . . . . . . . . . 18umeclidinium inhalation . . . . . 45UNI-HIST DROPS . . . . . . . . . . 41UNIPHYL . . . . . . . . . . . . . . . . . 46UNISOM . . . . . . . . . . . . . . . . . . 40UREA 10% CREAM . . . . . . . . 20UREA 10% LOTION . . . . . . . . 20urea 10%, urea 20% . . . . . . . . 20UREA 20% CREAM . . . . . . . . 20urea 40% . . . . . . . . . . . . . . . . . 20UREA 40% LOTION . . . . . . . . 20

URECHOLINE . . . . . . . . . . . . . 46UREX . . . . . . . . . . . . . . . . . . . . 46uridine . . . . . . . . . . . . . . . . . . . 24UROXATRAL . . . . . . . . . . . . . . 46ursodiol . . . . . . . . . . . . . . . . . . 26

VVAGIFEM . . . . . . . . . . . . . . . . . 35valacyclovir . . . . . . . . . . . . . . . . 29valbenazine . . . . . . . . . . . . . . . 16VALCYTE . . . . . . . . . . . . . . . . . 28valganciclovir . . . . . . . . . . . . . . 28VALIUM . . . . . . . . . . . . . . .33, 38valproic acid . . . . . . . . . . . . . . 16VALTREX . . . . . . . . . . . . . . . . . 29vancomycin powder for oral

solution . . . . . . . . . . . . . . . 28vandetanib . . . . . . . . . . . . . . . . . 5VAQTA . . . . . . . . . . . . . . . . . . . 50varenicline . . . . . . . . . . . . . . . . 41varicella virus vac live for

subcutaneous . . . . . . . . . . 51VARIVAX . . . . . . . . . . . . . . . . . 51VASERETIC . . . . . . . . . . . . . . . . 8VASOCIDIN . . . . . . . . . . . . . . . 36VASOCLEAR . . . . . . . . . . . . . . 36VASOTEC . . . . . . . . . . . . . . . . . . 8VECTICAL . . . . . . . . . . . . . . . . 18VEETIDS . . . . . . . . . . . . . . . . . 27VELTASSA . . . . . . . . . . . . . . . 11vemurafenib . . . . . . . . . . . . . . . . 5VENCLEXTA . . . . . . . . . . . . . . . 5venetoclax . . . . . . . . . . . . . . . . . 5venlafaxine . . . . . . . . . . . . . . . . 39venlafaxine XR . . . . . . . . . . . . . 39VENTOLIN HFA . . . . . . . . . . . . 45VEPESID . . . . . . . . . . . . . . . . . . 6verapamil . . . . . . . . . . . . . .10, 14verapamil extended-release . . 10VERIO . . . . . . . . . . . . . . . . . . . . 22

VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC . . . . . . . . . . . 22

VERZENIO . . . . . . . . . . . . . . . . . 4VESANOID . . . . . . . . . . . . . . . . . 7VFEND . . . . . . . . . . . . . . . . . . . 28VICODIN . . . . . . . . . . . . . . . . . . 13VICODIN ES . . . . . . . . . . . . . . . 13VICTOZA 2 PEN PACK . . . . . 22VIDEX . . . . . . . . . . . . . . . . . . . . 30VIDEX EC . . . . . . . . . . . . . . . . . 30vigabatrin powd pack . . . . . . . 16VIMPAT . . . . . . . . . . . . . . . . . . 15VINATE AZ EX . . . . . . . . . . . . . 48VINATE II . . . . . . . . . . . . . . . . . 48VIRACEPT . . . . . . . . . . . . . . . . 30VIRAMUNE . . . . . . . . . . . . . . . 29VIRAMUNE XR . . . . . . . . . . . . 29VIREAD . . . . . . . . . . . . . . . . . . 30VIROPTIC . . . . . . . . . . . . . . . . . 37VISINE-AC . . . . . . . . . . . . . . . . 36vismodegib . . . . . . . . . . . . . . . . 7VISTARIL . . . . . . . . . . . . . . . . . 20VISTOGARD . . . . . . . . . . . . . . 24vitamin A . . . . . . . . . . . . . . . . . 48vitamin ADC/fluoride/±iron

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

folic acid . . . . . . . . . . . . . . . 48vitamin B-1 . . . . . . . . . . . . . . . . 48VITAMIN B-12 . . . . . . . . . . . . . 47vitamin B-6 . . . . . . . . . . . . . . . . 48vitamin C . . . . . . . . . . . . . . . . . 48VITAMIN D 1000 UNIT . . . . . . 47VITAMIN D 2000 UNIT . . . . . . 47VITAMIN D 400 UNIT . . . . . . . 47vitamins pediatric . . . . . . . . . . 48VITRAKVI . . . . . . . . . . . . . . . . . 5VIVELLE . . . . . . . . . . . . . . . . . . 35VOLTAREN . . . . . . . . . . . .12, 32

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VOLTAREN 1% TOPICAL GEL . . . . . . . . . . . . . . . . . . 32

VOLTAREN XR . . . . . . . . .12, 32voriconazole . . . . . . . . . . . . . . 28vorinostat . . . . . . . . . . . . . . . . . . 4VOSEVI . . . . . . . . . . . . . . . . . . 29VOSOL HC OTIC . . . . . . . . . . 20VOSOL OTIC . . . . . . . . . . . . . . 20VOTRIENT . . . . . . . . . . . . . . . . . 5VYNDAMAX . . . . . . . . . . . . . . 12VYNDAQEL . . . . . . . . . . . . . . . 12

Wwarfarin . . . . . . . . . . . . . . . . . . . 7WELLBUTRIN . . . . . . . . . . . . . 39WELLBUTRIN SR . . . . . . . . . . 39WELLBUTRIN XL . . . . . . . . . . 39WIXELA INHUB . . . . . . . . . . . 45WYTENSIN . . . . . . . . . . . . . . . 11

XXALATAN . . . . . . . . . . . . . . . . . 37XALKORI . . . . . . . . . . . . . . . . . . 4XANAX . . . . . . . . . . . . . . . . . . . 38XELODA . . . . . . . . . . . . . . . . . . . 4XENAZINE . . . . . . . . . . . . . . . . 16XIIDRA . . . . . . . . . . . . . . . . . . . 35XOLAIR . . . . . . . . . . . . . . . . . . 45XOPENEX RESPULES . . . . . . 46XULANE . . . . . . . . . . . . . . . . . . 34XYLOCAINE . . . . . . . . . . . .19, 21XYZAL . . . . . . . . . . . . . . . . . . . 20

Yyuvafem or estradiol vaginal

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

ZZADITOR . . . . . . . . . . . . . . . . 36

zalcitabine . . . . . . . . . . . . . . . . 30zaleplon . . . . . . . . . . . . . . . . . . 40ZANAFLEX . . . . . . . . . . . . . . . 33zanamivir . . . . . . . . . . . . . . . . . 29ZANTAC . . . . . . . . . . . . . . . . . . 25ZARONTIN . . . . . . . . . . . . . . . 15ZAROXOLYN . . . . . . . . . . . . . . 10ZARXIO . . . . . . . . . . . . . . . . . . . 7ZEBETA . . . . . . . . . . . . . . . . . . . 9ZEBUTAL . . . . . . . . . . . . . . . . 12ZEJULA . . . . . . . . . . . . . . . . . . . 6ZELBORAF . . . . . . . . . . . . . . . . 5ZENTANE . . . . . . . . . . . . . . . . . 16ZERIT . . . . . . . . . . . . . . . . . . . . 30ZESTORETIC . . . . . . . . . . . . . . 8ZESTRIL . . . . . . . . . . . . . . . . . . . 8ZETIA . . . . . . . . . . . . . . . . . . . . 11ZIAC . . . . . . . . . . . . . . . . . . . . . . 9ZIAGEN . . . . . . . . . . . . . . . . . . 29zidovudine . . . . . . . . . . . . . . . . 30zinc . . . . . . . . . . . . . . . . . . .36, 48ziprasidone . . . . . . . . . . . . . . . 41ZITHROMAX . . . . . . . . . . . . . . 27ZOCOR. . . . . . . . . . . . . . . . . . . 11ZOFRAN . . . . . . . . . . . . . . . . . . 24ZOFRAN ODT . . . . . . . . . . . . . 24ZOHYDRO ER . . . . . . . . . . . . . 13ZOLINZA . . . . . . . . . . . . . . . . . . 4ZOLOFT . . . . . . . . . . . . . . . . . . 39zolpidem . . . . . . . . . . . . . . . . . 40ZOMACTON . . . . . . . . . . . . . . 23ZONEGRAN . . . . . . . . . . . . . . 16zonisamide . . . . . . . . . . . . . . . 16ZOSTAVAX . . . . . . . . . . . . . . . . 51zoster vaccine live . . . . . . . . . . 51zoster vaccine recombinant

adjuvanted . . . . . . . . . . . . . 51ZOVIA 1/35 . . . . . . . . . . . . . . . 34

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

TABLET . . . . . . . . . . . . . . . 20ZYTIGA . . . . . . . . . . . . . . . . . . . 5ZYVOX . . . . . . . . . . . . . . . . . . . 31

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

Name of Medicine and Strength

Drug Tier

I Take This Medicine For Directions Doctor

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

preferred drug list (pdl) · this preferred drug list ( pdl) to be used when prescrbi ni g for...

Documents